Just like shopping online for Christmas presents, the real hassle with providing drugs for NTDs is not finding the right supplier or best cost, it’s ensuring they arrive on time and in optimal condition. Pharmaceutical companies may have pledged billions of free vaccines for diseases in developing countries but these drugs cannot travel on good will alone.
The journey that vaccines take, known as the vaccine supply chain, is in dire need of improvement according to a report published in the International Journal of Logistics Systems and Management.
“Supply chain efficiency… is a matter of life and death,” says Professor Hokey Min of the College of Business Administration, Bowling Green State University, Ohio.
Links in the supply chain
A number of hurdles lay in store for vaccines crossing continents. Economics, politics and the infrastructure of a developing country often do not match the innovation of the drugs themselves. With more products trying to reach remote destinations and each requiring different storage environments, a robust but flexible supply chain is needed.
The majority of immunisation programs were launched in the 1970s and contain six vaccines – measles, tetanus, diphtheria, whooping cough (pertussis), tuberculosis and polio. The archaic supply chain that exists in most countries today makes do for these vaccines despite the high levels of waste they create along the way, almost 50% in some cases. The cost of updating the system would be better spent on developing the vaccines.
The traditional set of six vaccines is relatively cheap to produce, between US$0.10 and US$0.25 per dose. Funding for new vaccine development has upped the price, in the region of US$3.65 and US$15.00 per dose. The same proportion of wastage cannot be tolerated.
Conventional vaccines are usually packed in 10- and 20-dose vials, whereas the new ones are in 1- or 2-dose vials. To ensure the dose is delivered correctly, the new vaccines often come with individual or pre-loaded syringes and other delivery devices which can require upwards of 500 times the storage space.
Wastage of life-saving drugs is a huge problem. Scandals of drugs expiring in government warehouses held up in red tape or managed by under-trained staff are rife. In 2006, the expiration of US$500,000 worth of antiretroviral drugs in Uganda in government stores caused international outrage.
The most common loss to vaccines is heat-damage. Vaccines are biological products that can be damaged by high or freezing temperatures and excessive light as well as being subject to a use-by date. The optimum temperature range for vaccines is 2-8 degrees but maintaining this from factory to health centre is almost impossible.
The Hepatitis B vaccine is seriously damaged at temperatures less than 0 and freezes at less than -0.5. Even if the optimum temperature is regained, the vaccine is useless. 75% of shipments were frozen from provincial to district warehouses in Indonesia in 2004.
Vaccines have to endure repeated freezing and thawing cycles, inconsistent electrical systems and a lack of backup electricity supply. A study in Australia blamed inadequate storage of vaccines for an outbreak of diphtheria in 1993-6. A localised outbreak of measles in 1970 in the US was attributed to the vaccines being stored in door of the fridge rather than inside.
As advanced as new vaccines may be, there will still be a point in their journey where they travel on a dirt-track to a far away village in a cooler box. In a study conducted by PATH in 2008, vehicle failure accounted for 16% of vaccine damage with only a third of transportation being deemed generally satisfactory.
Stock levels are rarely accurate, resulting in too much vaccine lying around in warehouses for too long or stock outs in places where treatment is desperately needed. In the 57 countries that contributed, a staggering 27% of warehouses did not conduct physical stock counts with only a third fully or substantially correct stock and half in an orderly fashion. Significant incidences of stock outs were reported from 40% of countries.
A number of programs have been initiated to deal with the supply chain problems faced in developing countries. PATH and WHO have launched a five-year program that applies scientific and technological advances to the current supply chain to test new processes and systems. Project Optimize analyses supply chains in developing countries and introduces new systems to speed up and make the process more reliable.
For example, like health systems in most developing countries Albania maintains a paper-based registry of immunisations. Optimize will introduce a digital information registry and SMS-based temperature alarm system to monitor cold chain equipment.
Although adding another link into the supply chain, programmes such as Optimize will ultimately get vaccines to the estimated three million people whose lives are saved by immunisation each year.