Many vaccine supply chains around the world do not have enough storage and transport space to handle the flow of vaccines. (Photo courtesy of AMP)
As pictured here, many vaccine supply chains around the world do not have enough storage and transport space to handle the flow of vaccines. (Photo courtesy of Melanie Avella and Agence de Médecine Préventive-AMP)
Here’s a news flash. Vaccines have to actually reach people to work. In other words, if a vaccine never reaches a person, it cannot protect anyone from disease. And when the vaccine is not used, it goes to waste. You may think, isn’t this obvious? Sort of like, if a doughnut does not make it to your mouth, you cannot eat it?
Well, for many years, vaccine supply chains seemed like Jan Brady, Robin, Silent Bob or Chewbacca of the vaccine world, getting much less attention than other seemingly “more sexy” aspects of the vaccine world such as developing new vaccines and finding ways to pay for vaccines. (Yes, I said it, Chewbacca is not as sexy as Princess Leia…or Han Solo, depending on whom you prefer.) But “less sexy” doesn’t mean less important or less challenging an issue.
At first glance, getting vaccines to the people may seem like a straightforward endeavor. After all, when you order a book, clothes, kitchenware, belly button lint, a human hamster wheel or 55 gallons of lube over the Internet, it seems to show up magically on your doorstep. But remember, you aren’t seeing the many complex steps and hurdles involved. Also, books and large amounts of lube are not the same as vaccines. Vaccines have to travel thousands of miles over oceans, across rough terrain, past animals and bandits (and animal bandits), by political and social strife and through inclement weather, passing through many different hands. All the while, vaccines are like popsicles. Exposure to heat for too long makes the proteins in the vaccine fall apart, rendering it useless. Once this occurs, there’s no returning the vaccines to their original form (just like popsicles). At the same time, vaccines are like flowers, potentially falling apart when temperatures go too low. Yes, vaccines are like popsicle flowers, except much, much more useful and important.
Vaccine supply chains are the series of steps, processes, refrigerators, freezers, vehicles and personnel required to pass vaccines from the vaccine manufacturer to the country and then eventually all the way to the locations where the vaccines are finally administered to people. Without vaccine supply chains, vaccines cannot make it to the people. Without making it to the people, vaccines can’t do anything. And when vaccines can’t do anything, the vaccines and money go to waste.
Two male health workers riding a motorcycle down a dirt hill, carrying a vaccine carrier and supplies.
Two health workers riding a motorcycle down a dirt hill, carrying a vaccine carrier and supplies. (Photo credit: Doune Porter. Provided by Amy Wales, PATH)
As Benjamin Schreiber, Senior Immunization Specialist at UNICEF who has led numerous vaccine supply chain evaluation and improvement initiatives, explains, “Suboptimal supply chains can delay vaccine introductions, leading to wastage of expensive vaccines (by exposing them to damaging temperature extremes), and bottlenecks in the system can reduce the availability of all vaccines at the access points–leaving children and families unprotected from vaccine-preventable disease”
Many vaccine supply chains around the world are outdated, similar to ill-fitting leisure suits. For example, numerous low- and middle-income countries have vaccine supply chains that were designed in the late 1970s and 1980s. Back then, pioneers such as Andrew Garnett, John Lloyd, James Cheyne, Anthony Battersby and Lionel Pierre helped design many vaccine supply chains around the world, benefiting countless children and mothers. But while these supply chains worked well at the time, since then, many things have changed. Populations have grown. Diseases have evolved. A number of new vaccines have reached the market. And pastel-colored Miami Viceleisure suits are no longer cool.

A closer look reveals that many vaccine supply chains are indeed operating like suits that are too small to fit. It is not uncommon to visit a storage facility in a low- or middle-income country and find an overflow of vaccines that never make it to the people who are supposed to receive the vaccines. Storage locations often do not have enough refrigerator or freezer space to hold vaccines. Vehicles may not be available to help transport vaccines or lack enough storage space. There may not be enough trained people to handle the different parts of the supply chain. Supply chains may lack coordination and a proper means of communication, especially in remote areas. Electric power may not be reliable in some areas.
Vaccines can lose their potency over time or when exposed to too high or too low temperatures. Such waste can lead to the loss of money and lives.
Vaccines can lose their potency over time or when exposed to too-high or too-low temperatures. Such wasted vaccines means wasted money and for the people who never receive the vaccines potential suffering and even death. (Photo credit: Simona Zipursky. Provided by Amy Wales, PATH.)
Indeed, numerous vaccine supply chains around the world just aren’t doing their job…and when they are doing their job, it isn’t efficient. For example, one of our HERMES computational modeling studies,published in the American Journal of Public Health, found that the Niger vaccine supply chain had numerous bottlenecks, resulting in vaccines being available for only 69% of people arriving at health clinics. As another example, described in our article in the journalVaccine, the Republic of Benin recognized the need to re-design their vaccine supply chain after a December 2008 external review of their routine immunization program found high maternal and infant mortality (397 out of every 100,000 mothers and 67 out of every 1,000 infants) and that at least 15% of children were not currently receiving the complete set of recommended vaccinations. A technical support team including the Agence de Médecine Préventive (AMP), ourHERMES logistics modeling team (based at the Johns Hopkins Bloomberg School of Public Health and the Pittsburgh Supercomputing Center at Carnegie Mellon University), PATH and Transaid worked with the Benin Ministry of Health to explore different potential redesigns of the Benin vaccine supply chain. In a third example, as described in theExpert Review of Vaccines, introducing in 2006–2007 two new rotavirus vaccines revealed many problems with vaccine supply chains in Latin and South America. GlaxoSmithKline’s Rotarix and Merck’s RotaTeq vaccines overwhelmed the limited amount of available storage and transport capacity, clogging up the vaccine supply chains in different countries so that all vaccines (not just the rotavirus vaccines) had difficulty reaching the people.
An Intellectual Ventures Lab blog calculated the yearly wastage for just polio vaccine alone: Each year, purchasing the two billion doses of oral polio vaccine (OPV) at 14.6 cents a dose costs over $270 million. With almost 40% of these doses are wasted each year, over $100 million of OPV are wasted. It would take only a decade to reach $1 billion of wasted OPV. Then, consider the number of other types of vaccines given each year around the world such as hepatitis B, measles and rubella (together or separately), Haemophilus influenzae type B, rotavirus, HPV, etc. and you can see how billions of dollars of vaccine could be lost over time.
Paying closer to supply chains and coming up with new approaches, technology and designs have transformed some other industries. For instance, Walmart’s competitive advantage has been its ability to keep its shelves stocked with products demanded by consumers but also ensuring that products don’t sit on the shelves too long. Walmart’s product supply chain allowed this advantage over competitors with less efficient and effective supply chains. Amazon is all about supply chains. If you haven’t figured it out already, Amazon strength is not in developing and manufacturing products. (You can stop looking for Amazon-brand pants or candy bars.) Amazon has been able to take orders for and ship other manufacturers products faster, cheaper and more effectively than even the product manufacturers themselves. Of course, supply chains in different industries are different. And vaccine supply chains have their unique aspects and challenges. So improving vaccine supply chains doesn’t just mean taking what’s done in other industries to the vaccine world.
In recent years, the tide has been turning so that more attention and efforts have focused on improving vaccine supply chains in low- and middle-income countries. Organizations and groups such as the the World Health Organization (WHO), Gavi, UNICEF, Bill and Melinda Gates Foundation, PATH, JSI, Village Reach, Logistimo, our HERMES Logistics Team, the Clinton Foundation, the International Vaccine Access Center (IVAC) and UPS have dedicated efforts towards helping improve vaccine supply chains. This video from PATH and the WHO’s Regional Office for Africa discusses some of these efforts:
This Sunday (September 4), the 10th Annual Vaccine Congress in Amsterdam will feature a panel discussing the state of vaccine supply chains. (I am on the organizing committee for the Vaccine Congress.) One of the panelists will be Raja Rao, senior program officer at the Bill and Melinda Gates Foundation and a leading vaccine supply chain authority. Rao is helping lead the charge to transform vaccine supply chains around the world. His funding portfolio includes a wide variety of innovative projects aiming to improve vaccine supply chains. As Rao states, ”New approaches should consider an end-to-end supply chain solution from distribution and inventory policies to new technologies for storage and delivery of vaccines. Information systems that track where the vaccines are and how many children receive them is also essential to this new approach. This is even more important now as countries scale up the number of vaccines available, and the solution options presented to them by the changing role of information systems, digital health solutions and the role public health programs in managing it all so immunization programs can meet the needs of more children.”
Ultimately, vaccines can help prevent disease, avoid suffering and save lives. But they have to reach people to do their job. Yes, with life, doughnuts and vaccines…the journey matters.