Vaccine wastage rates and attributed factors in rural and urban areas in Uganda: Case of Mukono and Kalungu districts

doi:10.21203/rs.3.rs-4339026/v1

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Research Article

Vaccine wastage rates and attributed factors in rural and urban areas in Uganda: Case of Mukono and Kalungu districts

https://doi.org/10.21203/rs.3.rs-4339026/v1

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Background

Vaccine wastage contributes to missed opportunities to vaccinate especially in low-income countries with high vaccine preventable disease burden. We estimated vaccine wastage rates and assessed attributed factors among health workers participating in vaccination activities in Mukono and Kalungu districts in Uganda.

Methods

A mixed methods study design was utilised to estimate vaccine wastage rates for BGC, OPV, IPV, PCV, MR, DPT–HepB–Hib and assess attributed factors among health workers participating in vaccination activities in randomly selected health facilities in Mukono (urban) and Kalungu (rural) districts. Mann–Kendall statistical test was used to assess significance of observed trends of vaccine wastage rates. We applied Mann Whitney U and Kruskal–Wallis H tests to compare overall average vaccine wastage rates per vaccine by district, ownership, and type of health facility. For purposes of triangulation, we conducted Key informant interviews among immunization focal persons to explore reasons attributed to vaccine wastage. Thematic analysis method using inductive coding was used to analyse qualitative data.

Results

Overall vaccine wastage rates were BCG (70%), MR (58%), DPT–HepB–Hib (21%), IPV (31%), OPV (28%) and PCV (17%); exceeding accepted vaccine wastage rates in Kalungu and Mukono districts from March–August, 2022. Significant variations in vaccine wastage rates were observed across the different types of health facilities [BCG (p < 0.001), IPV (p = 0.023), MR (p = 0.004) and OPV (0.008)] and further, among health facilities located within urban and rural areas [BCG (p < 0.001), MR (p < 0.001) and OPV (0.003)]. Vaccine wastage rates particularly for BCG and MR vaccines were attributed to compliance with Multi Dose Vial Policy (MDVP). Other contributing factors were low turn up during vaccination outreaches, errors and non–completion of vaccine monitoring tools, failure in maintaining cold chain and lack of training in vaccine management among health workers.

Conclusion

Vaccine wastage rates for all vaccines were relatively higher than acceptable levels in both districts. Intensified efforts such as regular review of vial opening guidelines, predictive modelling for outreach planning, decentralized vaccination approaches, and availability of vaccines in single-dose presentations where feasible could minimize vaccine wastage especially in multi–dose vials.

Vaccine wastage

vaccine wastage rates

risk factors

rural

urban

Uganda

Vaccination is one of the most cost–effective and life–saving public health intervention (1, 2). In Uganda, traditional vaccines administered included tuberculosis vaccine (BCG), Oral Polio Vaccine (OPV), Measles –monovalent, and Diphtheria–Pertussis–Tetanus (DPT). With support from GAVI and other partners, Uganda has progressively introduced new vaccines into the routine vaccination schedule: pentavalent vaccine (DPT–HepB–Hib) in 2002; Pneumococcal Conjugate Vaccine (PCV–10) in 2013; Inactivated Polio Vaccine (IPV) and Human Papilloma Vaccine (HPV) in 2015; Rotavirus vaccine in 2018 and Measles rubella vaccine (MR) in 2019. In Uganda, the Ministry of Health (MoH) in Uganda, operating through the Uganda National Expanded Programme on Immunization (UNEPI), utilizes the healthcare system's framework to deliver vaccination services. These services are coordinated across multiple tiers, including national, regional, district, and community levels, each involving various stakeholders. Vaccines are regularly distributed from the National Medical Stores (NMS) to District Vaccine Stores (DVS) on a monthly basis to ensure consistent availability throughout the country. Vaccines are then allocated based on consumption demand, the quantity of vaccines needed by health facilities based on the rate at which they are consumed or used by the target population. In the calculation of consumption demand, factors such as target coverage rates, population demographics, historical vaccination data, and expected wastage rates are typically considered.

Vaccination services are delivered by skilled healthcare professionals, whose numbers vary based on the level of care provided, both in public and private healthcare facilities. In 2019, Uganda's vaccination coverage estimates indicated commendable performance, particularly with third dose Diphtheria, Tetanus, and Pertussis (DPT3) at 93%, Pneumococcal Conjugate vaccine (PCV3) at 92%, Polio 3 at 92%, BCG at 88%, completed dose of Rotavirus vaccines at 87%, and first dose of Measles-containing-vaccine (MCV1) at 87% (3). During the COVID-19 pandemic, there was a decline in routine immunization coverage (4).

Vaccine wastage, defined as the proportion of doses discarded in opened or unopened vaccine vials that are not used to vaccinate an eligible individual, contributes to missed opportunities to vaccinate (MOV) (5). Vaccine wastage has significant financial consequences, impacting healthcare budgets and potentially hindering immunization program sustainability. Vaccine wastage significantly impacts the cost-effectiveness of vaccine procurement, as each dose wasted represents a loss of the initial investment in vaccine procurement, necessitating additional procurement to compensate for wasted doses (6). Each wasted dose not only represents a loss in terms of the vaccine itself but also the resources invested in its handling and delivery for example storage, transportation, and distribution. The financial burden of managing and disposing of wasted vaccines further impacts on the already constrained health budgets by diverting resources away from other essential health services. Overall, vaccine wastage leads to missed opportunities for optimizing resource allocation since additional invested resources could have been utilized in other health care interventions (7).

General guidelines for Vaccine Wastage Rates (VWR) recommend acceptable rates for different vaccines: 50% for BCG and 25% for reconstituted measles vaccine, 10% for OPV, 15% for liquid vaccines in multi-dose vials containing 10 or more doses, and 5% for liquid vaccines in single or two-dose vials like PCV (8, 9). Notably, it’s quite challenging to balance between efficient provision of vaccines to targeted children and the need to minimize vaccine wastage for multi-dose vaccines. In Uganda, the Ministry of Health has recommended that health workers should open a multi dose vial even if one child turns up at the immunization centre to reduce missed opportunities for vaccination. While the aim is to optimize vaccine coverage, the inflexible rule surrounding the disposal of opened multi-dose vials at the end of a vaccination session or within a stringent six-hour timeframe, unless the vaccine meets the criteria for use for up to 28 days after opening, leads to significant vaccine wastage rates (10). Vaccine usage and wastage should be monitored monthly at all service points. Based on the 2014 Effective Vaccine Management Assessment (EVMA) report, Uganda lacked tools for monitoring vaccine wastage rates at different levels (11). Following the development of tools for estimating vaccine wastage by UNEPI, only 11% of health facilities calculated wastage rates, largely due to the absence of decentralized training sessions aimed at instructing healthcare workers on the methodology for calculating vaccine wastage (12). To this effect, Uganda does not have locally generated vaccine wastage estimates that can guide forecasting and need estimation. Consequently, the country has continued to rely on WHO projected wastage rates to estimate vaccine needs.

Under estimation of vaccines can lead to stock outs of a particular vaccine and increase missed opportunities for vaccination (MOV), one of the contributing factors to low vaccination coverage and eventual vaccine preventable disease outbreaks. On the other hand, over estimation of vaccines can lead to over stocking of a particular vaccine, leading to vaccine expiry before utilization. Estimating vaccine wastage rates for different vaccines can guide planners in accurately estimating the vaccine needs, hence maximizing utilization of available resources. Of note, health workers are expected to ensure that vaccine wastages are minimized to acceptable levels. This underscores the urgent need to estimate vaccine wastage rates and understand attributable factors among health workers to inform policy efforts towards minimising vaccine wastage in Uganda.

Additionally, existing literature indicates that logistical challenges, infrastructure limitations, and variations in healthcare delivery systems between rural and urban areas could influence vaccine wastage rates. In low- and middle-income countries, vaccine wastage rates were significantly higher in rural areas compared to urban areas (8, 13–17). This discrepancy was attributed to inadequate cold chain infrastructure, health care access, longer travel distances, population density, vaccine delivery logistics and limited healthcare facilities in rural settings, all of which could contribute to increased wastage. Other factors contributing to the disparities in vaccine wastage between rural and urban areas include hesitancy towards vaccination, apprehensions about vaccine safety, and limited accessibility to healthcare facilities, particularly in remote or hard-to-reach communities. Moreover, prolonged waiting times at health facilities, coupled with lower educational attainment among both residents and healthcare workers in rural settings, further compound these challenges. Furthermore, variations in population density between rural and urban areas can impact the efficiency of vaccine distribution and utilization. Based on these findings, we hypothesized that vaccine wastage rates would be higher in rural settings compared to urban settings in Uganda. This informed the decision to select Mukono and Kalungu districts to represent urban and rural settings respectively. We estimated vaccine wastage rates and assessed attributed factors among health workers participating in vaccination activities in Mukono and Kalungu districts in Uganda.

Study site

The assessment was carried out in randomly sampled health facilities providing vaccination services in Mukono and Kalungu; the urban and rural districts respectively. Data collected from the two districts also provided an opportunity to compare vaccine wastage rates to compare potential disparities with respect to rural and urban, type of health facility (hospitals and health centres classified as II, III, and IV) and ownership (private versus public health facilities) variations in Uganda. Mukono and Kalungu districts were grouped under Category 1 with good vaccine access and vaccine utilization as per the 2019/20 WHO Reaching Every District (RED) Categorization for measuring routine vaccination performance (18). Selection from the same category counteracted any inherent differences which could have been attributed to performance. The two districts are located in the central part of the country. Mukono district has a higher number of health facilities, forty–five compared to Kalungu with twenty–two health facilities providing vaccination services. According to the 2014 Population and Housing census, the population of Mukono was almost double that of Kalungu (19).

Study design and sampling procedures

Mixed methods study design was utilised to estimate vaccine wastage rates and assessed attributed factors among health workers participating in vaccination activities in Mukono and Kalungu districts in Uganda. In the quantitative phase, we computed monthly vaccine wastage rates for BGC, OPV, IPV, PCV, MR, and DPT–HepB–Hib for a period of 6 months. Furthermore, we compared vaccine wastage rates by type of health facility, ownership and district, and assessed attributed factors among health workers participating in vaccination activities. For purposes of triangulation, the qualitative phase explored reasons for vaccine wastage among health workers participating in vaccination activities in the two districts.

At the district level, a roster of health facilities categorized by their respective levels (including hospitals and health centres designated as II, III, and IV) was compiled using data extracted from the DHIS2 database. Health facilities that had not been providing vaccination services for the past six months were excluded. The decision to collect data for six months in our longitudinal study in only two districts was based on the need to balance the objectives of observing trends over time with the practical considerations of financial constraints. The investigative team believed that six months would be a sufficient reasonable time frame to observe, analyse trends and detect any noticeable patterns or fluctuations in wastage rates. While a longer duration might have provided more comprehensive insights, we aimed to maximize the utility of available resources while still striving to achieve the study's objectives effectively.

Based on the DHIS2 database, Mukono and Kalungu districts had forty–five and twenty–two health facilities providing vaccination services as of December 2022. Using a table of random number generator, a third of eligible public and private health facilities were randomly selected from the list of health facilities per district. Fifteen health facilities, comprising 3 hospitals, 7 HC IIIs, 1 HC IV, and 4 HC IIs, were randomly chosen from Mukono district. Similarly, seven health facilities, including 1 hospital, 1 HC IV, 3 HC IIIs, and 2 HC IIs, were randomly selected from Kalungu district, all of which offered vaccination services. Additionally, we administered a questionnaire among all available health workers providing vaccination services to identify reasons for vaccine wastage in selected health facilities.

For the qualitative phase, two Assistant District Health Officers in charge of maternal and child health services at the district level and twenty-two immunization focal persons from selected health facilities were eligible to participate in Key Informant Interviews. Out of twenty-four eligible key informants, twelve Key Informant Interviews were conducted based on the data saturation point; a point at which further sampling did not generate any new concepts or ideas about the phenomenon under investigation.

Data collection

Vaccine monitoring data for BGC, OPV, IPV, PCV, MR and DPT–HepB–Hib were extracted from Vaccine and Material Injection Control Book (VIMCB) and tally sheets using the abstraction tool from March–August, 2022. Information collected on a monthly basis required to calculate the monthly vaccine wastage rate as per the WHO recommended formula included: number of usable doses at the beginning of the month/starting monthly balance of vaccine doses, number of vaccine doses received during the month, number of usable doses in stock at the end of the month/monthly closing balance of doses, and number of doses administered/number of children vaccinated. A questionnaire, developed based on available literature, was administered among health workers providing vaccination services to describe reasons for vaccine wastage in their respective health facilities.

Qualitative data was collected in a single session at the beginning of the study using the key informant interview guide among Assistant District Health Officers and immunization focal persons at the selected health facilities. The Key Informant Interview guide was specifically developed for this study with questions aimed at eliciting reasons for vaccine wastage in health facilities. The Key Informant Interview guide was pre–tested and recommended changes in the questions were made to ensure that the guide captured relevant and appropriate information before use. Key Informant Interviews were conducted in English and audio–recorded on receipt of informed consent. Verbatim transcripts were proof–read before importing them into Atlas.ti version 6.0, a qualitative data management software

Data analysis

The monthly vaccine wastage rate was computed based on WHO–recommended formula for calculating wastage rate (5).

At the health facility level, monthly vaccine wastage rates for BGC, OPV, IPV, PCV, MR and DPT–HepB–Hib were computed from March–August 2022. At the district level, average vaccine wastage rate for each vaccine per month was calculated by adding vaccine wastage rates from selected health facilities divided by the number of health facilities. The overall average vaccine wastage rate for each vaccine was determined by adding average vaccine wastage rates per month divided by the number of months. Mann–Kendall statistical test was utilized to assess the significance of observed trends of vaccine wastage rates based on Kendall’s tau correlation coefficient (r) and p–values. We applied Mann Whitney U test to compare overall average vaccine wastage rates for BGC, OPV, IPV, PCV, MR and DPT–HepB–Hib by type of district (rural versus urban districts) and ownership (private versus public health facilities). For type of health facility, we applied Kruskal–Wallis H test to compare vaccine wastage rates since we had more than two categories of health facilities. This statistical test was selected to determine any differences in the average vaccine wastage rates because outcome data was not normally distributed. Significance was determined at a p–value of < 0.05. Furthermore, we calculated proportions of reasons for both closed– and open–vial vaccine wastage reported by health workers. Data analysis was conducted using Stata/SE Version 14.0.

Thematic analysis method using inductive coding was used to analyse qualitative data. Exploration of data and synthesis of codes, subthemes and themes was done in Atlas.ti Version 6.0. Relevant verbatim quotations were selected as evidence to support the generated themes.

Vaccine wastage rates

The overall average vaccine wastage rates were: BCG (70%), DPT–HepB–Hib (21%), IPV (31%), MR (58%), OPV (28%) and PCV (17%) in Kalungu and Mukono districts from March–August, 2022. Overall vaccine wastage rate for BCG (70%) was the highest, followed by Measles Rubella (58%) among all vaccines (Table 1). Notably, average vaccine wastage rates in Kalungu and Mukono districts exceeded the acceptable rates during the evaluation period (Fig. 1).

Table 1

Vaccine wastage rates in Kalungu and Mukono districts, March–August, 2022
Vaccine	Average vaccine wastage rates (%)		Overall average vaccine wastage rates (%)
Vaccine	Kalungu	Mukono	Overall average vaccine wastage rates (%)
BCG	77	63	70
DPT–HepB–Hib	23	19	21
IPV	33	28	31
MR	66	50	58
OPV	33	22	28
PCV	19	15	17

Monthly average vaccine wastage rates, March–August, 2022

In Kalungu district, average vaccine wastage rates for BCG and Measles Rubella vaccines were higher compared to other vaccines from March–August, 2022 (Fig. 2). The IPV vaccine demonstrated a significant increase in wastage in June followed by a decline in July, while the BCG vaccine exhibited its highest wastage rate in August compared to other months and vaccines. In July, there seems to be a noticeable decrease in the wastage rates for most vaccines compared to the previous months.

In Mukono district, average vaccine wastage rates for BCG and Measles Rubella vaccines were higher compared to other vaccines from March–August, 2022 (Fig. 3). Over the months, there are variations in wastage rates for each vaccine, which do not follow a uniform trend across all vaccines.

Trends of vaccine wastage, March–August, 2022

Despite increasing and decreasing trends observed based on the Mann–Kendall statistic and Kendall’s tau correlation coefficient, they were not statistically significant for all vaccines in Kalungu and Mukono districts (Table 2).

Table 2

Trends of vaccine wastage, March–August, 2022
Vaccine	Mann–Kendall statistic (S)	Kendall’s tau correlation coefficient	p–value
Kalungu District
BCG	276	0.09	0.235
DPT–HepB–Hib	35	0.05	0.692
IPV	46	0.04	0.680
MR	–122	–0.05	0.548
OPV	–41	–0.02	0.821
PCV	–120	–0.15	0.181
Mukono District
BCG	28	0.04	0.734
DPT–HepB–Hib	45	0.09	0.495
IPV	–6	–0.01	0.932
MR	136	0.18	0.102
OPV	17	0.03	0.834
PCV	–24	–0.09	0.568

Comparison of average vaccine wastage rates by district and ownership, March–August, 2022

Vaccine wastage rates for all vaccines were higher in Kalungu District compared to Mukono District. Significant differences in average vaccine wastage rates for BCG, MR and OPV were observed between Kalungu and Mukono districts (Table 3). There were no statistically significant differences in average vaccine wastage rates for all vaccines between public and private health facilities (Table 3).

Table 3

Comparison of average vaccine wastage rates by district and ownership, March–August, 2022
	Vaccine wastage rate (%)		p–value
District	Kalungu (Rural)	Mukono (Urban)	p–value
BCG	77	63	<0.001***
DPT–HepB–Hib	23	19	0.688
IPV	33	28	0.719
MR	66	50	<0.001***
OPV	33	22	0.003**
PCV	19	15	0.551
Ownership	Public HFs	Private HFs
BCG	72	67	0.845
DPT–HepB–Hib	13	23	0.051
IPV	29	30	0.087
MR	55	56	0.681
OPV	22	28	0.188
PCV	14	17	0.138

p < 0.05 p < 0.01 p < 0.001

Comparison of average vaccine wastage rates by type of health facility, March–August, 2022

Significant differences in average vaccine wastage rates for BCG, IPV, MR and OPV were observed between different types of health facilities as indicated in Table 4. Vaccine wastage rates were higher in level II health centres across all vaccines.

Table 4

Comparison of average vaccine wastage rates by type of health facility, March–August, 2022
Vaccine	Vaccine wastage rate (%)				p–value
Vaccine	Hospital	HC IV	HC III	HC II	p–value
BCG	51	66	68	82	<0.001***
DPT–HepB–Hib	16	36	17	21	0.488
IPV	17	27	25	52	0.023*
MR	50	66	51	63	0.004**
OPV	20	41	23	26	0.008**
PCV	12	23	15	18	0.235

p < 0.05 p < 0.01 p < 0.001

Characteristics of survey participants

Out of 57 health workers, most health workers (n = 30, 52.6%) were providing vaccination services in Health Centre IIIs. Of note, (n = 39, 68.4%) had only completed certificate programs whereas 47.4% served as enrolled midwives or nurses. Based on self–reports, (n = 20, 35.1%) of the respondents had participated in vaccination activities for 10 years and above.

Reasons for vaccine wastage

For closed vial vaccine wastage, the primary contributing factors identified were expiry of vaccines (14%), vaccine storage space constraints (11%), and cold chain failure (2%) (Fig. 4). On the contrary, open vial vaccine wastage exhibited a more varied set of reasons, with discarding reconstituted vials after 6 hours and discarding open vials after vaccination being the most prevalent factors, at 96% and 93% respectively.

Characteristics of key informants

Most key informants were Assistant Nursing Officers (n = 7, 47%) whereas the majority (n = 9, 60%) had provided vaccination services for 5 − 9 years (Table 5).

Table 5

Characteristics of immunization focal persons who participated in Key informant interviews in Kalungu and Mukono districts
Variable	Frequency (n = 15)	Percentage (%)
Cadre of health worker
Assistant District Health Officer (MCH)	2	13
Assistant Nursing Officer	7	47
Enrolled Midwife	3	20
Nursing Assistant	3	20
Years of service in vaccination activities
2–4	1	7
5–9	9	60
10 and above	5	33

Reasons for vaccine wastage highlighted during Key Informant Interviews among immunization focal persons in selected health facilities in Kalungu and Mukono Districts have been stipulated below:

High vaccine dosage vial

All immunization focal persons attributed vaccine wastage to high vaccine vial dosage coupled with the practice of opening a vial even if there is one child at the vaccination session to reduce missed opportunities among eligible children. BCG and Measles Rubella vaccines were the most affected vaccines since their opened multi–dose vials should be discarded at the end of the immunization session, or within six hours of opening.

“…they always say that even if you get one kid please endeavor to immunize, when you open up that vaccine you immunize one or two kids the rest of the vaccine is wasted, that is where I see wastage.” KII 06, Enrolled Midwife

“If a mother delivers a baby, that baby must be vaccinated before the mother is discharged. Yes, because we don’t want this child to miss BCG vaccine. But do you what this means… It means that after vaccinating this baby, I will waste the remaining 9 doses because I have to discard them after 6 hours…” KII 07, Assistant Nursing Officer

Low turnup during vaccination outreaches

Most immunization focal persons reported that they had encountered wastages during vaccination outreaches attributed to low turnup of eligible children. Despite continued efforts to utilize Village Health Teams (VHTs) for mobilization, health workers do not meet the targeted numbers of children expected increasing the chances for vaccine wastage at the end of vaccination outreaches.

“Yes, we involve them (VHTs) but the main issue during rainy season we don’t get much we don’t get many children because the parents are always in the gardens, yeah… their turn up is low. We don’t get many… sometimes, you have opened a Measles Rubella vaccine for one child… And you are forced to discard the remaining doses because other eligible children did not turn up.” KII 03, Assistant Nursing Officer

Errors and non–completion of vaccine monitoring tools

The majority of immunization focal persons reported non–completion and inconsistencies in documenting receipt and issuing of vaccines hence underestimation or overestimation of vaccine wastage rates. Even though health workers providing vaccination activities have been trained in completing vaccine monitoring tools, vaccines received and those issued out have not been accurately recorded in Vaccine and Material Injection Control Book. Accurately estimating vaccine wastage rates in these facilities is difficult due to poor data generation and quality.

“… actually, look at the tally sheets and the control book they speak totally a different language so you might record it as a wastage but in actual sense it is what was given out but it was not recorded properly…” KII 15, Assistant District Health Officer (MCH)

Failure in maintaining cold chain

Some immunization focal persons complained of frequent power fluctuations which destabilize the cold chain system. Such scenarios have led to wastage of batches of vaccines especially in lower health facilities without alternative sources of power like generators and solar fridges.

“In our facility, we have not yet received a solar fridge… And yet, sometimes we don’t have electricity. Recently, there was no electricity throughout the day till the next day… We were forced to discard the vaccines because of the undesirable red signal off the Vaccine Vial Monitor” KII 11, Assistant Nursing Officer

In such instances, health workers revealed that they had to transfer vaccines to health facilities with power or any other places of convenience. One of the key informants said,

“…for sometimes power goes off and we don’t have back up but we keep on monitoring our what, we keep on monitoring our fridge when we see the temperature is going up, we take our vaccines to another health facility with power… I remember there was a time we had to transfer fridges to the police station so that we maintain the cold chain.” KII 03, Assistant Nursing Officer

Lack of training in vaccine management

Several immunization focal persons reported that most of the health workers providing immunization services have not received training in vaccine management with an objective of minimizing vaccine wastage. Of note, some of the health workers who previously received the training have been transferred to other units whereas others were terminated or resigned especially in private health facilities.

“You see… most of us have never been trained on vaccine wastage issues… Whatever little we know, we had to ask our colleagues in the same health facility or even call in another health facility… Sometimes we are not even sure whether what we are doing is the correct thing to do…” KII 04, Assistant Nursing Officer

One of the district officials commented on poor reconstitution practices by health workers who are new and inexperienced saying that,

“…of late we have gotten more of young nurses coming on board and the expertise of giving a shot is another issue so they could be drawing more, …. so the vaccination skill is also another reason which contributes to the wastage as well…” KII 01, Assistant District Health Officer (MCH)

Overall vaccine wastage rates exceeded accepted vaccine wastage rates in Kalungu and Mukono districts from March–August, 2022. Significant variations in vaccine wastage rates were observed across the different types of health facilities and further, among health facilities located within urban and rural areas. Remarkably, vaccine wastage rate for BCG was the highest, followed by Measles Rubella compared to DPT–HepB–Hib, IPV, OPV and PCV. Vaccine wastage rates were attributed to high multi–dose vaccine vials complemented by compliance with Multi Dose Vial Policy (MDVP) where opened multi–dose vials for BCG and MR vaccines should be discarded at the end of the immunization session, or within six hours of opening (10). Other contributing factors were low turn up during vaccination outreaches; errors and non–completion of vaccine monitoring tools; failure in maintaining cold chain and lack of training in vaccine management among health workers.

Acceptable vaccine wastage rates are: 50% for BCG; 15% for DPT–HepB–Hib and IPV; 5% for PCV; 25% for Measles vaccine; and 10% for OPV (8, 9). In this evaluation, overall vaccine wastage rates were higher than acceptable vaccine wastage rates, contrary to findings from Cameroon where wastage estimates during 2016 and 2017 were at an acceptable level (8). Vaccine wastage rates for DPT–HepB–Hib, MR, IPV, OPV and PCV were higher compared to those recommended by Ministry of Health and Family Welfare (MoHFW) in India (20). It’s quite difficult to compare estimated vaccine wastage rates with general projected wastage rates and mathematical modelling to ascertain the discrepancies in Uganda. Country specific vaccine wastage rates have not been provided since data regarding vaccine wastage rates has been sporadic and unreliable. Such evidence gaps make it difficult to reliably forecast and redistribute antigens since there are no realistic estimates of vaccine wastage rates to guide procurement and supply of vaccine.

High vaccine wastage rates for BCG and MR compared to other vaccines have been reported; demonstrating coherence to existing literature from Cameroon, Gambia and Bangladesh (8, 21, 22). This could be accounted by high vaccine dose vial coupled with the application of Multi Dose Vial Policy. Multi–dose vaccine vials exhibit higher vaccine wastage rates compared to single or lower dose vaccine vials unless they are used in mass vaccination activities (23, 24). Transition from 5– to 10–doses vials for rotavirus vaccine increased vaccine wastage rates in India (20). Very slight differences between estimated and permissible vaccine wastage rates for BCG and MR were attributed to smaller 10 and 5–dose vials. However, there were large differences between IPV and OPV vaccine wastage rates and acceptable levels due to high 25–dose vaccine vial presentation (25). Evidence based findings indicate that high number of doses in a vaccine vial increase the chances for vaccine wastage at the expense of compliance with the MDVP, unless the vaccine meets the criteria for use for up to 28 days after opening. Daily vaccination was recommended to reduce missed opportunities for vaccination. However, this practice contributes to increased vaccine wastage since a 10 or 20 dose vial should be opened even if there is one child; discarding the remaining doses for BCG and MR vaccines without preservatives.

Health workers proposed several strategies to balance the efficient provision of vaccines to targeted children with the need to minimize vaccine wastage, particularly for multi-dose vaccines. Advocating for regular review of vial opening guidelines would allow health workers to assess real-time demand during the immunization session. There is need to consider guidelines that permit opening vials based on the number of children present, ensuring a more efficient use of vaccines. Improve planning for vaccination outreaches by employing predictive modelling and data analytics to estimate the number of attendees accurately. This can help health workers anticipate demand, optimize resource allocation, and minimize the risk of vaccine wastage at the end of the session. Explore the feasibility of setting up mobile vaccination clinics or pop-up sites in areas with lower turnouts. This decentralized approach, organized in collaboration with communities, can bring immunization services closer to local populations, potentially increasing the number of children reached and minimizing wastage associated with centralized sessions.

Public health authorities should advocate for the manufacture of vaccines in single-dose presentations where feasible. While this might not be applicable to all vaccines, it can be a viable solution for certain immunizations, eliminating the challenge associated with multi-dose vials. Establish a mechanism for regular review of immunization guidelines to ensure they align with current realities and technological advancements. This includes revisiting policies on vial openings, storage, and disposal to adapt to the evolving needs of the immunization program. These strategies should be prioritized to ensure successful roll out of upcoming multi dose vaccines, ensuring the benefits of vaccination reach as many individuals as possible while minimizing wastage. Our finding of higher vaccine wastage in a rural district compared to the urban districts is consistent with earlier findings. Peer reviewed studies and reports have reported variations across vaccine wastage rates among health facilities located within the urban and rural areas (26–29). Vaccine wastage rates are higher in rural areas compared to urban areas. These discrepancies could be explained by population density, coverage and frequencies of providing vaccination. Sparse populations and higher number of vaccination outreaches to complement static vaccination days have been highlighted among contributing factors to vaccine wastage in rural areas (8, 17, 20). Furthermore, differences in vaccine wastage rates have also been observed across the different types of health facilities. What is quite challenging was that some health facilities share targeted coverage areas and conduct vaccination outreaches in the same places; hence increasing incidences for wastages since expected eligible children might have been vaccinated by health workers from another health facility. In this regard, health workers should update micro plans to cater for recent changes in target populations and avoid overestimation of expected number of eligible children. Health workers should also engage in collaborative efforts with their counterparts in neighboring facilities to streamline vaccine service delivery and ensure comprehensive coverage within overlapping areas during the microplanning process.

The observed significant differences in average vaccine wastage rates among different types of health facilities, particularly higher rates in level II health centres across all vaccines, suggest potential disparities in vaccine management practices and resource utilization. Several factors may contribute to the higher wastage rates in level II health centres. These facilities often cater to smaller populations and may face challenges in maintaining optimal stock levels due to fluctuating demand. Additionally, limited storage capacity and inadequate infrastructure for cold chain management in level II health centres may contribute to vaccine spoilage and wastage. Furthermore, differences in vaccine delivery practices, such as handling procedures, storage conditions, and staff training, may influence wastage rates across health facility types. Level II health centres, with potentially fewer resources and staff compared to higher-level facilities, may face greater challenges in adhering to best practices for vaccine management, leading to increased wastage.

Routine stock monitoring of Vaccine vial monitors (VVMs) plays an important role in identifying challenges with the cold chain system and devising solutions (30, 31). Cold chain failures may expose vaccines to high temperatures if storekeepers and/or health workers do not know what to do in such cases. In developing countries like Uganda where electricity is unstable in rural area, it is common that vaccines will go to waste because of exposure to unfavourable temperature. In Cameroon, 65 health facilities lacked an alternative source of power which was significantly associated with abnormal temperature exposure (32). Vaccine wastages attributed to high temperature exposure should be prevented through installing alternatives sources of power. A better understanding of the vaccine rates due to supply chain and cold chain failures is imperative for generating rationalisation of the UNEPI and GAVI investments in cold chain maintenance and procurement.

Some of the immunization focal persons highlighted poor reconstitution practices by new and inexperienced health workers among the reasons for vaccine wastage. Health workers’ knowledge and practices of reconstitution contributes to vaccine wastage. Reconstitution practices can also lead to vaccine wastage most especially in cases where health workers are unaware of such wastages. A study assessing knowledge, attitudes and practices of vaccinators in Nigeria showed that 43% were knowledgeable about the discarding doses 6 hours after reconstitution (31). If the whole content of diluent is not used to reconstitute powder vaccine, fewer doses will be available in the vaccine vial for vaccination. Moreover, vaccines reconstituted with the wrong volume of diluent are likely to cause adverse events following vaccination. Information gaps as result of these practices continue to hide many costs associated with wastages yet can be prevented in the Ugandan health system.

Cost implications of vaccine wastage are multifaceted and can have significant impacts on healthcare systems, budgets, and overall public health efforts (33). Vaccine wastage result in substantial financial losses to healthcare providers, governments, and other stakeholders involved in vaccine distribution, particularly when dealing with expensive or limited-supply vaccines. Wastage doses not only represent the cost of the vaccine itself but also the resources invested in storage, transportation, and administration. In Cameroon, vaccine wastage exceeding the national targets amounted to 1,196.15 USD, which could cover the vaccination cost for 122 fully immunized children; with varying percentages attributed to BCG at 1.1%, OPV at 1.4%, DPT-HB-Hib at 72.7%, measles at 5.3%, and yellow fever at 19.5% (34). Moreover, wasted vaccines could have been utilized to protect vulnerable populations, thereby compromising public health efforts to control infectious diseases and other vaccine preventable diseases. Therefore, minimizing vaccine wastage is crucial for optimizing the effectiveness, equity, and sustainability of vaccination efforts. Health workers should be trained on how to complete vaccine monitoring tools for better data generation, quality, and utilization to support routine calculation of vaccine wastage rates. Monthly or routine collection of data on vaccine wastage rates enables health authorities to assess the efficiency of current practices, benchmark against standards, and make evidence-based decisions to improve resource allocation and policy development. Routine monitoring allows for the identification of trends over time, facilitating the evaluation of interventions and the tracking of progress in reducing wastage. Transparency and accountability are also promoted through reporting of wastage data, fostering trust within the healthcare system. Through systematically collecting and analyzing wastage rates, authorities can identify areas for improvement and implement targeted strategies to minimize wastage, ensuring that vaccines are utilized effectively to maximize public health impact.

Notably, it’s evident to focus on the collection and utilization of accurate data in resupply and forecasting processes is essential for effectively addressing vaccine wastage. By emphasizing the significance of seizing every opportunity to minimize losses, even if there are anticipated costs, this approach can lead to more efficient vaccine distribution and utilization, ultimately contributing to improved public health outcomes in the country. Determining vaccine needs for the immunization program requires multiplying together four key values: the target population, the number of doses in the schedule, the immunization coverage target, and the wastage factor (9). The wastage factor is derived by expressing the number of wasted doses as a percentage. This indicates that even if vaccine wastage rates exceed acceptable ranges, they are crucial and relevant for estimating vaccine needs accurately. By incorporating actual or historical wastage rates, tailored to local practices, into vaccine demand forecasting models, health authorities can ensure precise determination of the required quantity of vaccines to adequately serve the target population.

Study limitations

Vaccine monitoring tools were not completed especially receipt of extra vaccines during the month from the District Vaccine Stores or other health facilities. In such instances, the number of doses vaccinated exceeded the number of available doses throughout the month at the health facility. Of note, selected health facilities were not required to have all the data available as an inclusion criterion. Overall, approximately 5% of the data pool across all facilities was excluded during data analysis due to various reasons such as missing data, extra doses and inconsistencies in reporting in the Vaccine and Material Injection Control Book (VIMCB) and tally sheets. Exclusion of this data during affected months could have led to overestimation or underestimation of vaccine wastage rates for vaccines during the affected months and overall assessment period. Furthermore, this assessment was conducted in twenty–two health facilities in two districts in the entire country due to limited funding; hence affecting generalisability of study findings to all health facilities in Uganda.

This study underscores the critical challenges associated with high vaccine wastage rates, particularly for multi-dose vaccines, in Kalungu and Mukono districts of Uganda from March to August 2022. The observed variations in wastage rates among different health facilities, both in urban and rural areas, emphasize the complexity of the issue. Adherence to the Multi Dose Vial Policy (MDVP) emerged as a primary contributor to wastage, alongside factors such as low turnouts during vaccination outreaches and deficiencies in health worker training. We emphasize the urgent need for adaptive strategies including regular review of vial opening guidelines, employing predictive modelling for outreach planning, and exploring decentralized vaccination approaches. Additionally, the availability of vaccines in single-dose presentations where feasible could significantly mitigate challenges associated with multi-dose vials. Advocating for the utilization of actual or historical vaccine wastage rates, despite the possibility of surpassing acceptable ranges, while considering local practices, is vital for accurately forecasting vaccine needs and ensuring efficient resource allocation to seize every opportunity to vaccinate an eligible child. Immediate interventions, particularly in rural areas, are also necessary to strengthen the cold chain system, update micro plans, and enhance health worker knowledge, fostering a more efficient and effective immunization system in Uganda.

BCG Bacille Calmette–Guérin; CDC Center for Disease Control and Prevention; DPT Diphtheria, Tetanus (toxoid) and Pertussis vaccine; DVS District Vaccine Stores; EPI Expanded Programme on Vaccination; EVMA Effective Vaccine Management Assessment; GAVI Global Alliance for Vaccines and Vaccination; HC Health Centre; HepB Hepatitis B; Hib Haemophilus influenzae type b; HPV Human Papilloma Vaccine; IPV Inactivated Polio Vaccine; MDVP Multidose Vial Policy; MoH Ministry of Health; MoHFW Ministry of Health and Family Welfare; MOV Missed Opportunities to Vaccinate; MR Measles–Rubella; OPV Oral Polio Vaccine; PCV Pneumococcal Conjugate Vaccine; RED Reach Every District; UBOS Uganda Bureau of Statistics; UNEPI Uganda National Expanded Program on Vaccination; UNICEF United Nations Children’s Fund; VPD Vaccine Preventable Disease; VVM Vaccine Vial Monitor; WHO World Health Organization

Ethical approval and consent to participate

Approval to conduct the study was obtained from the Makerere University School of Public Health Higher Degrees Research and Ethics Committee (HDREC), National Council of Science and Technology and Uganda National Expanded Program on Immunization (UNEPI). Through the Ministry of Health, administrative clearance was sought from the offices of the District Health Officer (DHO) and Health Facility in–charges before conducting data collection. The research team ensured that all eligible participants provided informed consent and all interviews were conducted on a voluntary basis. A copy of signed informed consent was given to each respondent.

Interviewees were given the option to refuse to respond to particular questions or the whole interview, if at any time they believed a response would contain sensitive information or if they were not comfortable to answer. Responses were not linked to any specific person in the final report and all information provided was kept confidential and used for planning purposes only. The investigative team did not share responses of specific individuals with their co–workers and they were assured that whatever was said would not jeopardize their employment. Information that could be directly linked to individuals was not documented in this manuscript.

Availability of data and materials

The datasets upon which our findings were based belong to Ministry of Health. For confidentiality reasons, these datasets are not publicly available. However, they can be availed upon reasonable request from the corresponding author and with permission from Ministry of Health.

Conflict of interest

The authors declare no conflict of interest.

Consent for publication

Not applicable

Funding and disclaimer

This project was supported by East African Regional Centre of Excellence for Vaccines, Immunization, Health Supply Chain Management under the Cooperative Agreement number MUSPH# 1025 through Makerere University School of Public Health. Its contents are solely the responsibility of authors and do not necessarily represent the official views of East African Regional Centre of Excellence for Vaccines, Immunization, Health Supply Chain Management, Makerere University School of Public Health, or Ministry of Health. The staff of the funding body provided technical guidance in design of the study, ethical clearance, data collection, analysis, interpretation of data, and writing the manuscript.

Authors’ contributions

MN, MM, HL and SK designed the protocol and supervised data collection. MN drafted the manuscript. MN, MM, HL and SK critically reviewed the manuscript for intellectual content. All co–authors read and approved the final manuscript. MN is the guarantor of the paper.

Acknowledgments

The authors would like to thank research assistants; Simon Bakabulindi, Rehema Nabuufu and Catherine Atumanya who were very instrumental in collecting quantitative and qualitative data. Exceptional applaud to District Health Teams, immunization focal persons and health workers providing immunization services in Bukulula Health Centre IV, Kalungu Health Centre III, Kigasa Health Centre II, Kyamulibwa Health Centre III, St Monica Birongo Health Centre III, Teguzibizirwa Domicilliary Health Centre II, Villa Maria Hospital, Goma Health Centre III, Herona Hospital, Kasawo Health Centre III, Kojja Health Centre IV, Kyampisi Health Centre II, Kyetume Health Centre III, Kyungu Health Centre II, Mbaliga Health Centre III, Mukono General Hospital, Nagojje Health Centre III, Nakifuma Health Centre III, Nantabulirwa Health Centre II, Nyanja Health Centre II, and Takajjunge Health Centre III in Mukono and Kalungu districts.

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The authors declare no competing interests.

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Vaccine wastage rates and attributed factors in rural and urban areas in Uganda: Case of Mukono and Kalungu districts

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Study site

Study design and sampling procedures

Data collection

Data analysis

Results

Vaccine wastage rates

Monthly average vaccine wastage rates, March–August, 2022

Trends of vaccine wastage, March–August, 2022

Comparison of average vaccine wastage rates by district and ownership, March–August, 2022

p < 0.05 p < 0.01 p < 0.001

Comparison of average vaccine wastage rates by type of health facility, March–August, 2022

p < 0.05 p < 0.01 p < 0.001

Characteristics of survey participants

Reasons for vaccine wastage

Characteristics of key informants

High vaccine dosage vial

Low turnup during vaccination outreaches

Errors and non–completion of vaccine monitoring tools

Failure in maintaining cold chain

Lack of training in vaccine management

Discussion

Study limitations

Conclusion

List Of Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1

Vaccine wastage rates and attributed factors in rural and urban areas in Uganda: Case of Mukono and Kalungu districts

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Study site

Study design and sampling procedures

Data collection

Data analysis

Results

Vaccine wastage rates

Monthly average vaccine wastage rates, March–August, 2022

Trends of vaccine wastage, March–August, 2022

Comparison of average vaccine wastage rates by district and ownership, March–August, 2022

*p < 0.05 ** p < 0.01 *** p < 0.001

Comparison of average vaccine wastage rates by type of health facility, March–August, 2022

*p < 0.05 ** p < 0.01 *** p < 0.001

Characteristics of survey participants

Reasons for vaccine wastage

Characteristics of key informants

High vaccine dosage vial

Low turnup during vaccination outreaches

Errors and non–completion of vaccine monitoring tools

Failure in maintaining cold chain

Lack of training in vaccine management

Discussion

Study limitations

Conclusion

List Of Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1

p < 0.05 p < 0.01 p < 0.001

p < 0.05 p < 0.01 p < 0.001