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Impacts of Vaccine Cold Chain Logistics on Vaccine Epidemiology

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Impacts of Vaccine Cold Chain Logistics on Vaccine Epidemiology IMPACTS OF VACCINE COLD CHAIN LOGISTICS ON VACCINE EPIDEMIOLOGY by Tina-Marie Assi BS, McGill University, 2007 MPH, University of Pittsburgh, 2009 Submitted to the Graduate Faculty of Graduate School of Public Health in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2011 UNIVERSITY OF PITTSBURGH GRADUATE SCHOOL OF PUBLIC HEALTH This dissertation was presented by Tina-Marie Assi It was defended on June 30, 2011 and approved by Shawn T. Brown, PhD Assistant Professor Department of Biostatistics Graduate School of Public Health University of Pittsburgh Bryan A. Norman, PhD Associate Professor Department of Industrial Engineering Swanson School of Engineering University of Pittsburgh Jayant Rajgopal, PhD Associate Professor Department of Industrial Engineering Swanson School of Engineering University of Pittsburgh Stephen R. Wisniewski, PhD Professor Department of Epidemiology, Graduate School of Public Health University of Pittsburgh Dissertation Advisor: Bruce Y. Lee, MD, MBA Assistant Professor Departments of Medicine, Epidemiology and Biomedical Informatics School of Medicine and Graduate School of Public Health University of Pittsburgh ii Copyright © by Tina-Marie Assi 2011 iii Bruce Y. Lee, MD, MBA IMPACTS OF VACCINE COLD CHAIN LOGISTICS ON VACCINE EPIDEMIOLOGY Tina-Marie Assi, PhD University of Pittsburgh, 2011 The performance of vaccine logistics systems (i.e., the steps in a supply chain necessary to get vaccines from manufacturers to patients) can impact whether vaccines are delivered at the right time, place and in the right condition for patients during immunization sessions. Immunization coverage in a population depends on a well-functioning vaccine supply chain. If target populations are not immunized before exposure, they are left unprotected against vaccine preventable diseases (VPD’s) and can contribute to infectious disease transmission in their communities. Changes may be made to logistics systems without considering their potential effects on vaccine distribution and availability at vaccinating health centers. The combined works of this dissertation illustrate such changes and resulting impacts on vaccine availability, including: changes to vaccine presentations, changes to the vaccine supply chain structure, and changes to a vaccine regimen. The Vaccine Modeling Initiative (VMI) developed the Highly Extensible Resource for Modeling Supply chains (HERMES), a stochastic, discrete-event simulation model. VMI collected information on vaccine cold chain equipment (e.g., refrigerators and freezers), transportation fleets, demographic indicators for target populations, and supply chain operating policies (e.g., shipping frequencies) for the country Niger and for Trang province in Southern iv Thailand. HERMES was then used to evaluate various supply chain interventions and determine their impacts on logistics indicators including: vaccine availability at health centers, transportation and storage utilization, and additional capacity requirements. With over a dozen new vaccines being introduced into national immunization programs in the next decade, logistics systems will be further pressed to ensure vaccines are delivered to their target populations. These studies will highlight the importance of considering vaccine logistics systems when making changes to immunization programs, and suggest potential alternative strategies to improve the performance of supply chains and ultimately vaccination coverage rates. Furthermore, these studies will demonstrate the utility in using computational models to evaluate and provide solutions for public health challenges by representing relationships that would not otherwise be apparent. v TABLE OF CONTENTS PREFACE ................................................................................................................................. XIV 1.0 IMPACTS OF VACCINE COLD CHAIN LOGISTICS ON THE EPIDEMIOLOGY OF VACCINATION IN NIGER AND THAILAND ................................ 1 1.1 LITERATURE REVIEW ................................................................................... 1 1.1.1 Overview of vaccine supply chains ................................................................. 1 1.1.2 Vaccines in the Expanded Program on Immunization ................................ 2 1.1.3 Why model vaccine supply chains? ................................................................ 3 1.1.4 Existing and future challenges to sustainable vaccine supply chains ......... 7 1.1.5 Difficulties in estimating vaccine coverage .................................................. 10 1.1.6 VPD incidence and burden in unvaccinated populations .......................... 13 1.1.7 Overview of Thailand and Niger demographics, vaccination coverage and EPIs ......................................................................................................................... 16 1.1.8 Existing vaccine supply chain models .......................................................... 18 1.1.9 Addressing a gap in the literature ................................................................ 20 2.0 IMPACT OF CHANGING THE MEASLES VACCINE VIAL SIZE ON NIGER’S VACCINE SUPPLY CHAIN: A COMPUTATIONAL MODEL......................... 22 2.1 ABSTRACT........................................................................................................ 23 2.1.1 Background .................................................................................................... 23 vi 2.1.2 Methods .......................................................................................................... 23 2.1.3 Results ............................................................................................................. 23 2.1.4 Conclusions..................................................................................................... 24 2.2 INTRODUCTION ............................................................................................. 25 2.3 METHODS ......................................................................................................... 26 2.3.1 General Framework ...................................................................................... 26 2.3.2 Niger Vaccine Supply Chain and Data Sources .......................................... 26 2.3.3 Model Structure ............................................................................................. 27 2.3.4 Vaccine Specifications ................................................................................... 29 2.3.5 Supply Chain Performance Metrics ............................................................ 29 2.3.6 Sensitivity Analyses ....................................................................................... 31 2.4 RESULTS ........................................................................................................... 32 2.4.1 Overall Impact ............................................................................................... 32 2.4.2 Impact on Vaccine Administration .............................................................. 33 2.4.3 Impact on Vaccine Transport ....................................................................... 33 2.4.4 Impact on Vaccine Storage ........................................................................... 35 2.4.5 Impact on Vaccine Supply Chain Costs ...................................................... 36 2.5 DISCUSSION ..................................................................................................... 37 2.5.1 Limitations ..................................................................................................... 40 2.6 CONCLUSIONS ................................................................................................ 40 2.7 ACKNOWLEDGEMENTS .............................................................................. 41 2.8 FIGURES............................................................................................................ 42 2.9 TABLES.............................................................................................................. 45 vii 3.0 IMPACTS OF REMOVING THE REGIONAL LEVEL FROM THE NATIONAL VACCINE SUPPLY CHAIN IN NIGER ........................................................... 48 3.1 ABSTRACT........................................................................................................ 49 3.1.1 Background .................................................................................................... 49 3.1.2 Methods .......................................................................................................... 49 3.1.3 Results ............................................................................................................. 50 3.1.4 Conclusions..................................................................................................... 50 3.2 INTRODUCTION ............................................................................................. 50 3.3 METHODS ......................................................................................................... 52 3.3.1 Model Description.......................................................................................... 52 3.3.2 Description of the Niger Vaccine Supply Chain ......................................... 53 3.3.3 Structure of the Model .................................................................................. 54 3.3.4 Vaccine Characteristics ................................................................................
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