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Coverage, Cost, and Safety Impacts of Primary Container Choice

By: Cecily Stokes-Prindle & Lois Privor-Dumm, Leila Haidari, Diana Connor, Angela Wateska, Shawn Brown, and Bruce Lee International Access Center (IVAC) • Johns Hopkins Bloomberg School of Public Health | 1 International Vaccine Access Center (IVAC) Johns Hopkins Bloomberg School of Public Health Rangos Bldg, Suite 600 855 N. Wolfe Street Baltimore, MD 21205 www.jhsph.edu/ivac

Cecily Stokes-Prindle & Lois Privor-Dumm, Bloomberg School of Public Health Leila Haidari, Diana Connor, Angela Wateska, Shawn Brown, and Bruce Lee, HERMES Logistics Modeling Team, Johns Hopkins Bloomberg School of Public Health, University of Pittsburgh, and Pittsburgh Supercomputing Center (PSC).

This report was produced by the International Vaccine Access Center at Johns Hopkins University Bloomberg School of Public Health, with data from the HERMES model provided by the HERMES Logistics Modeling Team (http://hermes.psc.edu). We gratefully acknowledge the input of the following participants in the Primary Container Round- table: Orin Levine & Robert Steinglass (co-chairs), Muyi Aina, Edward Arcuri, Tajul Islam Abdul Bari, Endele Beyene, David Bishai, Carla Botting, Dmitri Davydov, Srihari Dutta, Serge Ganivet, Andrew Garnett, , Thomas Hensey, Suresh Jadhav, Phillipe Jaillard, Najwa Khuri-Bulos, Solo Kone, Debra Kristensen, Gordon Larsen, Tina Lorenson, Vivek Malhotra, Susan McKinney, Andrew Meek, Jules Millogo, Angeline Nanni, Jean-Marc Olivé, Jon Pearman, Olga Popova, Logan Rae, Raja Rao, Nora Lucia Rodriguez, Jeff Sanderson, Angela Shen, Chizoba Wonodi, and Prashant Yadev. We also thank Jennifer McManus and Kyung Min Song for their invaluable research assistance. 2 | Coverage, Cost, and Safety Impacts of Primary Container Choice • 2013 INTRODUCTION WHY NOW FOR PRIMARY A single decision on the size and type of a vaccine container can have significant CONTAINER WORK? implications on the safety, affordability, and coverage of in routine and campaign settings. Choosing a single dose vial instead of a multi dose container • New vaccine introductions are ramping up. If or a pre-filled syringe, for example, affects a wide variety of stakeholders: the we help manufacturers understand priorities vaccine recipients who benefit from the vaccine’s protection; the governments early, these can be addressed in product and organizations that buy, transport, and store them; the health workers who development to produce the greatest health administer and dispose of them; and manufacturers who make . value and deliver savings down the line. • For eradication, almost isn’t good enough. Given the scarcity of data on the broader effects of container choice, eradication is within reach, but only decisions are often based on readily quantifiable criteria with clear short- if vaccines can make it all the way to the term implications; procurement price or storage volume are common decision last child at the end of the last mile. drivers.1 These criteria provide a helpful starting point for decision-making; eradication efforts may be next, and will face however, container choices have additional complex impacts on safety, the same difficulty. Container choice could affordability, and coverage—particularly in low-resource, last-mile settings. be the small but crucial difference between eradication and continued transmission. While these concepts might seem abstract, they have already had very real • Many new vaccines cost more than traditional effects, in terms of both dollars spent and lives saved. In the early stages of vaccines, making high wastage rates even pneumococcal (PCV) introduction, manufacturers developed more costly.3,11 With traditional vaccines, a two dose presentation as a response to global health community requests for which are generally pennies per dose, low storage-volume options. However, unlike other multi dose liquid vaccines wastage is less costly, with an increasing used in routine , the two dose PCV vial was preservative-free, number of new, expensive vaccines, costs with new handling requirements to ensure safe, effective administration. due to wastage could increase substantially. The resulting need for training at the country level was extensive, and—in A more in-depth look is needed to understand the absence of systematic communication between countries, agencies, and the full cost implications of a new vaccine manufacturers—largely unanticipated. As a result, introduction was delayed in introduction, factoring in issues of wastage, several countries, increasing costs and leaving children unvaccinated.2 , health worker training, and the often hidden costs of adverse events The upcoming transition from oral to inactivated (IPV), an following immunization. injectable, provides another example of these tradeoffs in action—for instance, in the short-term, standalone IPV may be the most viable option, but with • Demand-side issues are likely to become how many doses per vial? Many countries prefer multi dose vials due to space more important. There are important constraints and price, but it’s currently unclear which presentations will be discussions going on in other container- available and prequalified, and whether multi dose vial policy will apply. impacted areas, such as the rise in public and environmental concerns about Furthermore, countries may want more than one option for different situations. thimerosal in multi dose vial vaccines. In areas where session sizes are small, single, or low dose options may make the most sense. Further into the future, decisions will center around combination vaccines, such as hexavalent diphtheria, , pertussis, , haemophilus influenzae type b, and IPV vaccine. This approach avoids extra shots but requires a preservative-free one or two dose container. Low dose options often come at a higher price and increase cold chain burden, but they also reduce wastage. In cases of limited resources or uncertain supply, the fear of wastage puts health care workers in a difficult position: with a multi dose vial and a small session size, do they open the vial and waste the unused doses, or do they wait for another day when there is a larger session size, avoiding wastage but leaving today’s eligible children unvaccinated? The “best” answer isn’t clear, and might be different from one place to another—but getting the answer right from the start could mean the difference between successful or an ongoing battle against the disease.

International Vaccine Access Center (IVAC) • Johns Hopkins Bloomberg School of Public Health | 1 HOW DO PRIMARY CONTAINER shortages; these disconnects could be a result of multiple factors, but an DECISIONS AFFECT COVERAGE, incomplete understanding of decisions at the clinic level may contribute to AFFORDABILITY, AND SAFETY? communication and forecasting failures. The difficult tradeoffs in coverage demonstrate the extent to which the “best” container choice will vary by COVERAGE context, and highlight the importance of better data for decision-making. As with safety, the pathways from container choice to coverage outcomes are complicated, and have not been well studied. To the Additionally, compact, pre-filled auto-disable devices (CPADs) reduce extent that multi dose containers reduce storage and transport burdens, the transportation and planning burden for ensuring availability of they may increase coverage by reducing space bottlenecks which may syringes. They also offer another benefit that can not be forgotten - prevent vaccines from reaching the places they need to reach. However, given that needles are already attached, there is no added risk that they can also affect health care worker behavior. If a health worker has children will not receive vaccine due to a shortage of needles at the three children at a session, but the needed vaccine is in a ten or twenty time of administration. dose vial , the health worker may have a dilemma. If the vaccine does not qualify for the multi dose vial policy (MDVP)* or the MDVP is not To illustrate the impact that these choices can have on coverage, followed, they may waste a lot of doses and possibly not have enough see Figure 1, which shows the impact on coverage of a 10-dose vial for children who come in later sessions; or, they may inappropriately with a 50% opening threshold. In other words, if a health care worker use the vaccine, potentially putting children at risk. Outreach to use the only opens a vial when at least half of that vial will be used, what is remaining doses is also an option, particularly with presentations such as the impact on coverage? As the figure shows, the impact varies by prefilled syringes or oral droppers, but the associated time and logistics session size. With larger session sizes, the coverage differences are required could be a significant challenge. very small. But in areas where sessions are between 1-10 children— as in many “last-mile” settings—coverage will decrease to 60% even In areas with uncertain supply, there is some evidence that health when the needed vaccines are technically available. workers are hesitant to open the vial, and children miss opportunities 3,4 for vaccination. Even if a worker does open the vial, the increase in Even in scenarios with larger average session sizes, coverage impacts wastage reduces overall supply and can result in shortages. On the other can be observed; in areas where sessions average between 11-20 hand, if the health center is supplied with only single dose vials, storage children, a 50% opening threshold decreases coverage to 92%. This constraints may prevent them from keeping enough vaccine on hand to is still a relatively high percentage, but it also represents a best case meet demand on any given day. In addition, there are reports of central scenario in which the needed vaccine is always available. When managers reporting adequate supply while regional managers report variations in availability combine with reluctance to open large vials, Figure 1. Percent coverage by session size range, if health care worker opens vial only for sessions where 50% of doses will be used.

The 50% “Opening Threshold”: If a health care worker only opens a vial when at least half of that vial will be used, what is the impact on coverage? With large session sizes, the coverage differences are small. But in areas where sessions are between 1-10 children—as in many “last-mile” settings—a 50% “opening threshold” will decrease coverage to 60% even when the needed vaccines are technically available. Even in scenarios with larger average session sizes, coverage impacts can be observed; in areas where sessions average between 11-20 children, a 50% opening threshold decreases coverage to 92%. This is still a relatively high percentage, but it also represents a best case scenario in which the needed vaccine is always available. When variations in availability combine with reluctance to open large vials, the coverage impacts will be larger. *MDVP states that under certain conditions, opened multi dose vials of OPV, DTP, TT, hepatitis B, and liquid formulations of Hib may be used in subsequent sessions for up to four weeks.

2 | Coverage, Cost, and Safety Impacts of Primary Container Choice • 2013 the coverage impacts will be larger. These impacts may be somewhat container lower procurement costs and require less space, reducing mitigated if children return to the clinic after an unsuccessful visit, storage needs, transport needs, and medical waste.5 For this but when health facilities are hard to reach, a return visit is a difficult reason, multi dose vials are generally considered the least expensive option. For eradication campaigns and last-mile efforts, these small option when procurement and logistics costs are considered alone. differences can be the difference between success and failure. However, increased global demand for a particular presentation may help lower procurement costs; as cost to manufacturer is not AFFORDABILITY directly related to price,6 procurement costs could be similar across The pathways from container choice to affordability outcomes presentations. Other costs, such as wastage or handling, may add are in some ways straightforward. Stakeholders, however, do not considerably to the overall cost of the vaccine program.7 Where always consider the impact of all aspects of affordability and may wastage is an issue in a country, the lower cost per dose delivered thus focus on one aspect—such as price per dose, or cost to add benefits of a multi dose vial may be erased as the system needs to additional cold chain storage— without considering other aspects. procure more product, transport it and store it. The characteristics of the container and the market affect the price charged by a manufacturer, and the country pays that price in As an illustration, consider the hypothetical scenario illustrated in addition to storage, transport, disposal, and wastage costs. Taken Figure 2 below. In this example, a hypothetical vaccine is priced together, all of these factors determine price per dose, cost per similar to Pneumococcal Conjugate Vaccine (PCV): $3.50 for a single vaccinated child, and overall affordability of a presentation. dose vial, $2.80 per dose in 5-dose vials, and $2.40 per dose in a Usually, presentations with a high number of doses in a single 10-dose vial. Figure 2. Average cost per dose administered by session size range, assuming that health care workers open vials as needed, and unused doses are wasted.

Multi dose vials are sometimes cheaper—but only for large session sizes. As an example, a hypothetical vaccine is priced similarly to pos- sible Pneumococcal Conjugate Vaccine (PCV) pricing: $3.50 for a single dose vial, $2.80 per dose in 5-dose vials, and $2.40 per dose in a 10-dose vial. As illustrated above, cost per dose administered is higher for a multi dose vial when sessions are small, and that relationship quickly reverses as session sizes increase. This demonstrates the need to consider multiple presentations in a single country, even when affordability is the primary concern.

ASSUMPTIONS

• Logistics costs are calculated per vial: $1.00 for the 10-dose, $0.70 for the 5-dose, and $0.50 for the single dose. Possible economies of scale in logistics costs are not represented.

• Price per dose is $3.50 for single dose vial, $2.80 for 5-dose vial, and $2.40 for the 10-dose vial.

• Distribution of session sizes is equal; no session size is weighted to reflect a more frequent occurrence.

International Vaccine Access Center (IVAC) • Johns Hopkins Bloomberg School of Public Health | 3 In this illustration, cost per dose administered is higher for a multi after a serious adverse event can also be significant. dose vial when sessions are small, and that relationship quickly reverses as session sizes increase. This demonstrates the need to INTERRELATIONSHIPS BETWEEN DOMAINS consider multiple presentations in a single country, even when There are also safety or coverage effects that influence affordability affordability is the primary concern. or vice versa. For example, the health worker choosing between wasting doses or leaving children unvaccinated will affect cost per Actions to keep wastage low (such as session size management or administered dose as well as coverage. If the worker opens the vial, compliance with multi dose vial policies) can help keep multi dose wastage costs increase, reducing the affordability of the multi dose vials affordable for small session sizes, even when cost per dose presentation. If the worker decides not to open the vial, the costs administered is considered along with procurement costs.8 Wastage of wastage are averted, but there may be increased costs of illness at earlier points along the supply chain (e.g., during transport or at and lost productivity from incidence of vaccine-preventable diseases the central cold store) should also be considered for a comprehensive in those unvaccinated children. Poor safety outcomes can increase cost per dose assessment. Additionally, investing in additional cold the cost of illness17 (particularly at the household level) while also chain options and/or reevaluating the structure of storage and delivery reducing coverage by depressing demand. options may be an affordable option over the long term. POLITICAL WILL AND DECISION-MAKING The manufacturer perspective on affordability is also important; as It is important to note that the relationships illustrated above exist noted earlier, price is not a fixed characteristic of a presentation, but within and alongside a series of similarly complicated political a function of the entire economic and technological environment. systems. While container choice is not inherently a political issue, Although single dose containers generally cost more, those agencies, governments, and funders set priorities which in turn affect differences do not fully account for the disparity in pricing between the range of options and willingness to prioritize different aspects presentations.9 Economies of scale help reduce price per dose; the of container decisions.18 Politics and policy are therefore key, albeit greater the demand for single dose product, the lower the possible indirect, components of the primary container decision system. cost per unit. If that demand can be reliably predicted, it can be leveraged to reduce prices. When demand is uncertain, however, SCENARIO ANALYSIS: ROUTINE manufacturers will necessarily be less flexible in price setting, and IMMUNIZATION IN BENIN affordability will be reduced. In a more concrete example of the importance of health care SAFETY worker decision-making, we can consider the variations in vaccine The pathways from container choice to safety outcomes are perhaps availability and cost per dose administered within a small country the most difficult to quantify, and have not been well characterized such as Benin. According to the Highly Extensible Resource to date. Essentially, increasing the doses per container increases for Modeling Event-Driven Supply Chains (HERMES) analyses the opportunity for user error,10 which may raise the likelihood of (conducted after an extensive data collection and verification non-sterile injections11 and injections with expired vaccine. In process), the national-level cost per dose administered, averaged turn, this increases the likelihood of from injection and across all vaccines, is $0.25. Reducing doses per vial for any of blood-borne disease transmission.12 Certain presentations may vaccine in the schedule increases the cost per dose administered, also increase the risk of accidental needle sticks, which put health and simulating a 50% opening threshold for each vial results in workers at risk of blood-borne disease.13,14 decreased vaccine availability.

The presence of preservatives may reduce the likelihood of some Subnationally, however, the picture varies. Simulating a 50% opening adverse outcomes, but thimerosal, the most commonly used threshold— a rule that vials are only opened when 50% or more of preservative, has been a target of concerned parents and activists the doses will be immediately used—yields differing results across due to its chemical relation to mercury.15 Furthermore, thimerosal the areas analyzed. In Natitingou and Kandi, two of the three areas may have antibacterial action, but is not effective in controlling with the lowest vaccine availability, a 50% opening threshold results viral contaminants. in slight increases in vaccine availability and reductions in cost per dose administered. This may indicate that current large vial sizes Additionally, public opinion can have a significant impact on are reducing overall availability due to open vial wastage. In the perceived safety of certain vaccines or the program overall; higher performing areas, applying a 50% opening threshold had regardless of actual safety, these concerns can lower demand and the opposite effect, increasing cost per dose administered and thus coverage.16 Costs to mitigate bad publicity or restart a program decreasing availability.

4 | Coverage, Cost, and Safety Impacts of Primary Container Choice • 2013 Figure 3. Vaccine Availability and Cost per In terms of threshold changes, the increases and Dose in Benin With and Without a Vial decreases of the largest magnitude were observed in Opening Threshold the areas with the highest baseline vaccine availability. However, variations in cost and coverage as a result of vial size changes were much smaller in the high availability areas, perhaps indicating a greater ability to adapt to changes in the system. Interestingly, variations in the number of health post trips needed as a result of vial size changes follow the same pattern in both high-availability and low-availability areas; as expected, reducing the doses per vial increases the number of trips necessary. However, the trips themselves are cheaper in high-availability areas, reducing the cost impact of the additional logistics burden.

WHAT IS THE CURRENT STATE OF PRIMARY CONTAINER DECISION-MAKING?

There is no comprehensive set of guidelines weighing the trade-offs of affordability, safety, and coverage. Decision makers from different sectors or regions will naturally have differing priorities, which may lead them to a focus on certain aspects over others. The resources available to a given decision-maker vary widely as well. In resource- limited settings, up-front costs, and current system capacity are very often the determining factors in container choice at the country level. Costs are most easily compared in terms of procurement prices. While price differences are certainly not trivial, changes in vaccine presentations can change other outcomes, such as wastage, that in turn change the cost per vaccinated child—even when price per dose procured remains the same.19, 20 On the Simulating a 50% opening threshold— a rule that vials are only opened when 50% flip side, choosing a presentation with a high volume per or more of the doses will be immediately used—yields differing results in different dose (such as a single dose vial) can lead to increased cold areas of Benin. In Natitingou and Kandi, two of the three areas with the lowest chain, transport, and personnel needs and costs.21 While vaccine availability at baseline, a 50% opening threshold results in slight increases in container choice almost certainly affects safety,22 there vaccine availability and reductions in cost per dose administered. This may indicate is little concrete evidence quantifying these effects; the that current large vial sizes are reducing overall availability due to open vial wastage. lack of data often excludes safety concerns from explicit In the higher performing areas, applying a 50% opening threshold had the opposite effect, increasing cost per dose administered and decreasing availability. consideration in container decisions.

International Vaccine Access Center (IVAC) • Johns Hopkins Bloomberg School of Public Health | 5 Improved market forecasting could spur product development. Mismatches between available presentations and country needs can create shortages or unnecessary burdens; when countries receive products that are not compatible with their systems, additional or unplanned investments may be required for successful introduction. Manufacturers are willing to develop new presentations in response to global health community requests. Historically, however, communication around desired characteristics has not been systematic or consistent, leaving manufacturers hesitant to invest in new product development.26 Accurate and transparent forecasting is needed to restore private sector confidence in the health community’s decisions.

Space reduction does not always equate to lowest cost. Many EPI managers will avoid adding cold chain capacity wherever possible. The most consistent source of guidance is the WHO prequalification The cost of new and incremental operational costs, are process, an established procedure used by WHO for the evaluation often lower than the wastage seen for multi dose vials. Adding cold of candidate vaccines. Prequalification provides a set of standards chain space may become a necessity anyway given the number for health products, including vaccines; a vaccine that has achieved of new antigens introduced in the coming years. Additional space WHO prequalification is eligible for purchase by UNICEF and other needed from single dose vials may have insignificant cost compared UN agencies. Prequalification requires that vaccine efficacy data and to the wastage savings and other benefits of safety and coverage that studies are relevant to the target population, and that vaccines meet could be seen assuming the country has the capacity to handle the specific criteria in terms of potency, thermostability, presentation, product. labeling, shipping conditions, and more.23 The prequalification process is enormously helpful in setting baselines and facilitating Stakeholder perspectives are complex and diverse. Decision- dialogue between manufacturers and global agencies. However, makers have different needs, priorities, and resources, even within a it cannot serve as a comprehensive analysis of all the issues particular stakeholder group. For instance, an EPI manager within a surrounding introduction in a particular country; prequalification country may want multi dose vials to minimize cold chain burdens, processes are necessarily operating at the global level, and they are but a health worker in the same country may have concerns about focused on efficacy and supply, rather than behavioral, policy, or opening a multi dose vial for a small session size and wasting demand-side impacts of introduction. doses,27 particularly if there’s uncertainty about the ability to restock in a timely manner. In addition, constraints differ between campaign There is a need to balance country and global perspectives. A settings and routine administration; some vaccines must fit in both one-size-fits-all, global approach commonly seen in low income contexts, as they are administered in both settings or transitioned to countries can lead to programs or policies that don’t meet the needs routine after an initial campaign period. of specific countries, or that don’t fit the needs of certain regions within a country.24 For instance, a country with limited cold storage High-priority data gaps have not been identified and addressed. may need to prioritize low volume above all other considerations, Important information such as wastage rates, cold chain capacity, regardless of international recommendations. Countries may also session sizes, safety outcomes, and cost per administered dose can find that session sizes in urban locations vary drastically from those be very difficult to pin down, particularly at subnational levels.28,29 in hard to reach areas, thus necessitating different size containers.25 The lack of data, particularly on safety, hinders evidence-based And in some cases, the initial investment of funding and human decision-making, and there is little ability to prioritize within existing resources necessary to set up— and maintain— an improved cold data gaps. Additional data on safety are needed for countries, chain may be out of reach, even if the investment case itself is clear. manufacturers, and donors to make better decisions; these data Cold chain investments are not always as high as they may seem should be incorporated into available tools such as HERMES to initially, however, and are often a cost-effective way to ensure that facilitate decisions based on all factors that should be considered. other priorities of coverage and safety are considered. This decision, therefore, should be taken with those objectives in mind, also taking into account that capacity may need to be added anyway to prepare for future vaccine introductions.

6 | Coverage, Cost, and Safety Impacts of Primary Container Choice • 2013 HOW CAN PRIMARY CONTAINER DECISIONS BE IMPROVED?

The public health community will be facing some very important decisions in the near future, which have implications not only for countries that introduce new vaccines, but for manufacturers who supply new product and countries, and INTERNATIONAL VACCINE donors who fund the process. Introduction of inactivated polio vaccine (IPV), ACCESS CENTER AT JOHNS recently recommended by SAGE30, and other new vaccines that will significantly HOPKINS BLOOMBERG expand countries’ immunization programs will have significant implications for all SCHOOL OF PUBLIC HEALTH stakeholders. Individual decisions, made on the basis of up-front indicators such as IVAC aims to improve access to life- cost or cold chain expense, have the potential to work against the long-term needs of saving vaccines by ensuring that the disease reduction and eradication effort in hard to reach locations. If multi dose vials evidence required for decision-making are used in hard-to-reach areas with small session sizes, potential impacts include is generated and synthesized, made high wastage levels, potentially resulting in insufficient supply; containers unopened available to policy-makers, and results and children turned away if a sufficient number of children are not in a session; in concrete action. Since 2003 – at a health worker spending additional time in outreach, which has direct costs and the start of the Pneumococcal Acceler- opportunity costs; or the retention of open multi dose vials, risking contamination. ated Development and Introduction Plan Single or low dose vials avoid those particular pitfalls, but they too come with (PneumoADIP), and continuing with the downsides. Some have suggested that perhaps a five dose vial is a solution, but it launch of IVAC in 2009 – we have cul- is important to evaluate whether that it will in fact address the issues that are to be tivated broad networks of stakeholders solved. Further, both global and country guidance will need to be vaccine specific, in order to integrate apparently dispa- taking into account price of vaccine, safety implications, how it is used, and other rate aspects of immunization systems, factors. More data are needed to understand the risks to enable all stakeholders to identify opportunities, anticipate needs, make fully informed decisions. and build effective partnerships.

It is clear that there is no “one size fits all” solution; answers will be very context Our HERMES team consists of experts specific, and some trade-offs will be unavoidable. However, running scenarios and from a variety of disciplines including modeling the impact in multiple ways may help answer some important questions operations research/industrial engi- and allow for more informed decision-making. Tools such as HERMES and other neering, vaccinology, , models can help provide detailed and dynamic simulations of country supply medicine, infectious diseases, computer chains,31 and be adapted to evaluate coverage and safety implications. In addition, science, and modeling from the Johns a comprehensive approach makes it possible to identify and evaluate innovative Hopkins School of Public Health, the opportunities, such as regional procurement or multiple presentations within a University of Pittsburgh, and Pittsburgh single country. Also, the manufacturers’ perspective will need to be considered as Supercomputing Center (PSC). The economies of scale derived from focus on a small number of product presentations HERMES team focuses on developing can be important. computational models and tools to help various decision makers better under- Having the data to support decisions could then result in policies that can be stand and assist vaccine distribution. evaluated in the context of the complex and dynamic environment that exists Our work involves working closely with today. Although there may still be trade-offs, the decision to select for instance a wide range of collaborators. a single dose vial in some countries or a ten dose container for the majority of a country and single, two or five dose container for the hard to reach areas will help in making better informed decisions to meet coverage goals, and in turn protect more children from vaccine-preventable diseases.

International Vaccine Access Center (IVAC) • Johns Hopkins Bloomberg School of Public Health | 7 1 International Vaccine Access Center. Meeting Minutes. A Roundtable on Consideration for Primary Vaccine Container Selection in Developing Countries – Defining the Evidence and Framework for Decision Making. May 9-10, 2012. International Vaccine Access Center. http://www.jhsph.edu/research/centers-and-institutes/ivac/resources/primary-container- roundtable/Primary-Container-Roundtable-Minutes.pdf. Accessed March 20, 2013. 2 UNICEF Supply Division. Pneumococcal Conjugate Vaccine: Current Supply & Demand Outlook. February 2013. http://www.unicef.org/supply/files/PCV_Supply_ Status_2013February_UNICEF_SD_Final.pdf 3 Steinglass R. 5-dose vials of for routine immunization programs? Technet-21. http://www.technet21.org/index.php/forum/technet21/vaccine-presentation-packag- ing-and-wastage/2791-5-dose-vials-of-measles-vaccine-for-routine-immunization-programs.html#p3965. 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8 | Coverage, Cost, and Safety Impacts of Primary Container Choice • 2013 International Vaccine Access Center (IVAC) • Johns Hopkins Bloomberg School of Public Health | 9 International Vaccine Access Center (IVAC) Johns Hopkins Bloomberg School of Public Health Rangos Bldg, Suite 600 855 N. Wolfe Street • Baltimore, MD 21205 www.jhsph.edu/ivac 10 | Coverage, Cost, and Safety Impacts of Primary Container Choice • 2013