This report attempted to document the vaccine wastage status for the vaccines in UIP in Kangra and Pune districts representing two different geographies, the hilly and plain regions. The use of two different sizes of RVV vials provided an opportunity for documenting the change in wastage rates. Additionally the transition from regular to fraction dose of IPV in Kangra during the observation period was also captured. We estimated the wastage for UIP vaccines at cold chain points and outreach session sites during two year period. This is the first report on wastage rate of RVV with both five and ten dosage vial package versions. Additionally this is the first report from India on wastage for PCV and transition of IPV to fIPV dosage under UIP.
The present study documented the wastage rates for all the vaccines to be universally higher for all vaccines than the recommended by Ministry of Health and Family Welfare (MOHFW). In Kangra, the wastage rates for OPV and fIPV were above 50%, for most of the other vaccines except LPV were in the range of 26–50%. For most of the vaccines the wastage was > 10% of the prescribed range, except Measles, LPV and RVV-5. In Pune, the wastage rates for most of the vaccines were < 25% except for BCG, DPT, fIPV, and RVV-10. For majority of the vaccines the wastage was within 10% of the prescribed range, except DPT, TT, and fIPV. For Measles and RVV-5, the wastage was lower than the prescribed range. Higher vaccine wastage rates in Kangra compared to Pune may be explained by the target population base, density and beneficiary load for the sessions. No wastage of unopened vials indicated good practices for storage, logistics and stock management at the cold chain stores.
Rise in the wastage rate with transition from RVV 5 doses to 10 doses vial in both districts can be explained by the beneficiary case load. With rising institutional deliveries, fewer beneficiaries for BCG vaccine at outreach session level may explain little higher wastage. The wastage rates for vaccines under open vial policy like DPT, fIPV may be higher due to lower number of beneficiaries within the usable window period of 4 weeks in the same session area. Despite higher wastage for fIPV (50 doses) dose practice, higher number of beneficiaries would have been vaccinated from the unit vial compared to IPV (10 doses) dose practice. Using the opened vaccine vial for sessions other than the session where it is opened may reduce the wastage of these multidose vaccine vials under open vial policy. The observed higher wastage rate for OPV in Kangra may be one off events during the period of observation.
A wastage assessment across nine districts across five states (Utar Pradesh, Himachal Pradesh, Tamil Nadu, Maharashtra, and Assam) in India (2010) by Unicef covering the full vaccine supply chain documented the average wastages for DPT, HBV, TT, Measles OPV and BCG to be 27% (19%-58%), 33% (30%-57%), 34% (20%-55%), 35% (26%-58%), 47% (40%-75%), and 61% (54%-68%) respectively. The wastage for four of the six vaccines were highest for Himachal Pradesh (BCG 65%, OPV 75%, Measles 58%, TT 53%, HBV 57% and DPT 58%) than Maharashtra (BCG 54%, OPV 51%, Measles 44%, TT 55%, HBV 37% and DPT 35%) (2). From Delhi the wastage for UIP vaccines including DPT, Measles, OPV, DT, TT and BCG were observed to be 38.6%, 39.9%, 48.1%, 57.3%, 62.8% and 70.9% respectively (5). A study in 10 districts across 4 states documented wastage for DPT (38.9%), DT (39.1%), and TT (48.1%) with no open vial policy practice, OPV (52.7%), BCG (49.3%) and Measles (38.7%). There was wide variation in the wastage rates across the districts and states (6). From urban area of Gujarat, the wastage for DPT, HBV, OPV, Measles and BCG were reported to be 16%, 21%, 25%, 28% and 45% respectively (7).
At a referral facility in Haryana, the wastage rates for LPV, OPV, TT, HBV, Measles, DPT and BCG were recorded to be 7.4%, 28.9%, 36.8%, 38.6%, 41.2%, 46.7% and 77.9% respectively (8).
At a teaching hospital in Puducherry, the vaccine wastage rates for UIP vaccines including DPT (8.4%), OPV (2.4%), HBV (5.3%,) LPV (0%), TT (4.2%) and TT (4.2%) to be within the prescribed limit, but for Measles (46.5%) was higher (9). The wastages for UIP vaccines at a tertiary hospital in Rajasthan were reported to be 9.2%, 9.4%, 12.7%, 21.3%, 27.6% and 29.4% for HBV, LPV, DPT, BCG, Measles and OPV respectively (10). From another referral facility in Madhya Pradesh, the wastage rates for LPV, TT, HBV, OPV, BCG and Measles were recorded to be 5.2%, 7%, 10.5%, 14.5%, 20.7%, and 21.6% respectively (11).
In an urban area of Gujarat, wastage of UIP vaccines like LPV, OPV, DPT and TT to be 47.8%, 50%, 42.7%, and 42% before adoption of open vial policy. The wastage declined by 1.8%, 6.2, 7.5% and 17.1% for DPT, TT, OPV and LPV vaccines respectively after adoption of open vial policy. With introduction of second dose of Measles vaccine, the wastage declined from 63.6–41.4% (12). Another report from urban Gujarat, across 24 health facilities the wastage for OPV declined from 25–13.6% and liquid vaccines (DPT, HBV, and LPV) from 17.9–8% with induction of open vial policy (13). In One district of Karnataka, the wastage rates for LPV, Measles, OPV, DPT and BCG were documented to be 24.5%, 32.5%, 41.4%, 50.2% and 64.6% respectively (14).
There have been some reports from other countries with varied levels of vaccine wastage. In Bangladesh, the wastage rate at primary service delivery level was documented to be 34.8%, 45.1%, 68.6% and 84.4% for the vaccines TT, DPT, Measles and BCG respectively. At the facility level, the wastage rates were 36.6%, 44.2%, 71.2% and 85.1% for the vaccines TT, DPT, Measles and BCG respectively. The wastage was > 25% for majority of the primary service and also facility levels for all vaccines (15). In a prospective study in Gambia, the wastage for lyophilised vaccines were documented to be higher for BCG (54.9%, 20 doses vial) followed by Measles (15.6%, 10 doses vial), LPV, IPV, TT, HBV, and DPT (0.1–5.1%, all 10 doses vials except TT, 20 doses vial). The wastage rates for single dose PCV and RVV were 0.1% and 5.2% respectively (16). Another prospective study in Nigeria, the wastage rates estimated at session sites were highest for OPV (35%) followed by BCG (30%), TT (30%), Measles (23%), HBV (22%), and DPT (21%). The wastage rates for vaccines at store level were highest for TT (28%) followed by Measles (27%), OPV (23%), BCG (22%), HBV (21%) and DPT (18%) (17). Based on reports from 19 countries, the median wastage rates for single, 2- and 10-dose vials were estimated as 5% (IQR 1–10%), 7% (IQR 1–27%) and 10% (IQR 4–44%) respectively (4).
There have been several efforts to make immunization program cost effective through appropriate adjustment in vaccine logistics, operation including session planning, vial reuse policy, vial size package, and vaccinator practice (18). It was estimated that with transition from 10- to 5-dose vials of IPV the open vial wastage would be reduced by nearly half in all countries; Bangladesh by 56% (from 0.25 to 0.11), India by 53% (from 0.17 to 0.08), Mozambique by 53% (from 0.13 to 0.06), and Uganda by 44% (from 0.09 to 0.04) (19).
The two states (Himachal Pradesh and Maharashtra) are common with the Unicef vaccine wastage study in five states (2). The vaccine wastage rates for most of the vaccines in both states have decreased overtime, which may be due to better organisation and logistics management, improved supervision and monitoring and open vial policy adoption. There has been wide variation in the vaccine wastage across the states and most of them have been from urban or tertiary care facilities. Limited information on vaccine wastage at outreach levels is available from different states in India to better understand the determinants. In our study, with transition from smaller to larger dose vial size, the wastage rate increases as documented for RVV and IPV in the current study. Reducing vial size has been an appealing strategy to reduce wastage, but cost-benefit analysis should be conducted considering the logistics and cold chain footprint, especially the costlier vaccines.
This study had several limitations. The study included only two districts and selected facilities in the districts. Some of the stores and outreach sessions had incomplete records, which may have introduced bias in the estimates. The period of record available for MR and PCV were relatively small.