Cost-effectiveness analysis of an intervention project engaging Traditional and Religious Leaders to improve uptake of childhood immunization in southern Nigeria.

Vaccination is a cost-effective public health intervention, yet evidence abounds that vaccination uptake is still poor in many low- and middle-income countries. Traditional and Religious Leaders play a substantial role in improving the uptake of health services such as immunization. However, there is paucity of evidence on the cost-effectiveness of using such strategies. This study aimed to assess the cost-effectiveness of using a multi-faceted intervention that included traditional and religious leaders for community engagement to improve uptake of routine immunisation services in communities in Cross River State, Southern Nigeria. The target population for the intervention was traditional and religious leaders in randomly selected communities in Cross River State. The impact of the intervention on the uptake of routine vaccination among children 0 to 23 months was assessed using a cluster randomized trials. Outcome assessments were performed at the end of the project (36 months).The cost of the intervention was obtained from the accounting records for expenditures incurred in the course of implementing the intervention. Costs were assessed from the health provider perspective. The cost-effectiveness analysis showed that the incremental cost of the initial implementation of the intervention was US$19,357and that the incremental effect was 323 measles cases averted, resulting in an incremental cost-effectiveness ratio (ICER) of US$60/measles case averted. However, for subsequent scale-up of the interventions to new areas not requiring a repeat expenditure of some of the initial capital expenditure the ICER was estimated to be US$34 per measles case averted. Involving the traditional and religious leaders in vaccination is a cost-effective strategy for improving the uptake of childhood routine vaccinations.

Challenges related to resources mobilization for measles outbreak response: Madagascar experience during the 2018-2019 measles outbreak.

INTRODUCTION: on October 4th, 2018, a measles outbreak was declared in Madagascar. This study describes challenges related to resources mobilization for the outbreak response. METHODS: data were collected using minutes of coordination committee meetings, activities reports, operational action plans and situation reports. RESULTS: the total cost of the outbreak response was estimated to US$ 11,281,381. Operational cost was the leading cost driver (42.45%) followed by vaccine cost (33.74%). Cases management, epidemiological surveillance, communication and social mobilization and routine immunization strengthening represented 23.81% of the total cost. The main funder of the outbreak response was the measles and rubella initiative. CONCLUSION: good coordination, open dialogue, good use of financial resources and accountability of government and partners have enabled to gain the confidence of national and international donors.

How much does it cost to measure immunity? A costing analysis of a measles and rubella serosurvey in southern Zambia.

BACKGROUND: Serosurveys are a valuable surveillance tool because they provide a more direct measure of population immunity to infectious diseases, such as measles and rubella, than vaccination coverage estimates. However, there is concern that serological surveys are costly. We adapted a framework to capture the costs associated with conducting a serosurvey in Zambia. METHODS: We costed a nested serosurvey in Southern Province, Zambia that collected dried blood spots from household residents in a post-campaign vaccine coverage survey. The financial costs were estimated using an ingredients-based costing approach. Inputs included personnel, transportation, field consumable items, social mobilization, laboratory supplies, and capital items, and were classified by serosurvey function (survey preparation, data collection, biospecimen collection, laboratory testing, and coordination). Inputs were stratified by whether they were applicable to surveys in general or attributable specifically to serosurveys. Finally, we calculated the average cost per cluster and participant. RESULTS: We estimated the total nested serosurvey cost was US $68,558 to collect dried blood spots from 658 participants in one province in Zambia. A breakdown of the cost by serosurvey phase showed data collection accounted for almost one third of the total serosurvey cost (32%), followed by survey preparation (25%) and biospecimen collection (20%). Analysis by input categories indicated personnel costs were the largest contributing input to overall serosurvey costs (51%), transportation was second (23%), and field consumables were third (9%). By combining the serosurvey with a vaccination coverage survey, there was a savings of $43,957. We estimated it cost $4,285 per average cluster and $104 per average participant sampled. CONCLUSIONS: Adding serological specimen collection to a planned vaccination coverage survey provided a more direct measurement of population immunity among a wide age group but increased the cost by approximately one-third. Future serosurveys could consider ways to leverage existing surveys conducted for other purposes to minimize costs.

[Measles vaccination: why and how?] / Mazelenvaccinatie: waarom en hoe?

The measles virus is highly contagious and may hit non-immune populations very hard, as observed on remote islands. The first live-attenuated measles virus vaccine was registered in the United States in 1963, and was imported to the Netherlands from 1968 onwards. Production was taken over by the National Institute for Public Health (RIV). Because the burden of disease was still high, measles vaccination was introduced into the Dutch National Immunisation Programme in 1976; since 1987 this has been in the form of the combined measles, mumps and rubella (MMR) vaccination. The MMR vaccine was also initially imported and later manufactured by the National Institute for Public Health and the Environment (RIVM). Since then, measles epidemics have almost exclusively affected unvaccinated populations. Vaccinated individuals are thus well-protected, as are unvaccinated individuals as long as the rate of vaccination in the surrounding population is sufficiently high. Unvaccinated individuals who travel to countries where measles is endemic are still at a higher risk. Recent studies show that measles not only has the classical symptoms, but also damages the immune system.

Recent setbacks in measles elimination: the importance of investing in innovations for immunizations.

The recent setbacks in efforts to achieve measles elimination goals are alarming. To reverse the current trends, it is imperative that the global health community urgently intensify efforts and make resource commitments to implement evidence-based elimination strategies fully, including supporting research and innovations. The Immunization Agenda 2030: A Global Strategy to Leave No One Behind (IA2030) is the new global guidance document that builds on lessons learned and progress made toward the GVAP goals, includes research and innovation as a core strategic priority, and identifies measles as a "tracer" for improving immunisation services and strengthening primary health care systems. To achieve vaccination coverage and equity targets that leave no one behind, and accelerate progress toward disease eradication and elimination goals, sustained and predictable investments are needed for the identified research and innovations priorities for the new decade.

The impact of vaccine procurement methods on public health in selected European countries.

Introduction: Across Europe, immunization programs have brought immense benefits to the prevention of infectious diseases. The vaccines used are procured through a variety of models such as tenders and Pricing & Reimbursement. However, to date, the impact of the procurement method on the performance and sustainability of vaccination programs and on public health has received little attention.Areas covered: Drawing on a review of the academic and policy literature, complemented by an interview program with stakeholders involved in the procurement of vaccines, the authors have documented the relationship between procurement method dynamics and the level of protection against vaccine-preventable diseases in Germany, Italy, Spain and Romania for, measles-containing vaccines, hexavalent and influenza vaccines.Expert opinion: Price-based tenders can contribute to vaccine supply issues, discourage the provision of value-added services supporting vaccination coverage and disincentives future R&D. Although it is observed that price-based tenders can intensify competition in the short term, there can be unintended consequences such as damage to long-term competition. As European countries are committed to strengthen their immunization programs, they should consider the implications of current vaccine procurement models on the vaccine ecosystem and on public health.

Cost effectiveness and policy announcement: The case of measles mandatory vaccination.

In a vaccination game, individuals respond to an epidemic by engaging in preventive behaviors that, in turn, influence the course of the epidemic. Such feedback loops need to be considered in the cost effectiveness evaluations of public health policies. We elaborate on the example of mandatory measles vaccination and the role of its anticipation. Our framework is a SIR compartmental model with fully rational forward looking agents who can therefore anticipate on the effects of the mandatory vaccination policy. Before vaccination becomes mandatory, parents decide altruistically and freely whether to vaccinate their children. We model eager and reluctant vaccinationist parents. We provide numerical evidence suggesting that individual anticipatory behavior may lead to a transient increase in measles prevalence before steady state eradication. This would cause non negligible welfare transfers between generations. Ironically, in our scenario, reluctant vaccinationists are among those who benefit the most from mandatory vaccination.

The cost saving opportunity of introducing a card review into measles-containing vaccination campaigns.

Measles vaccination is a cost-effective way to prevent infection and reduce mortality and morbidity. However, in countries with fragile routine immunization infrastructure, coverage rates are still low and supplementary immunization campaigns (SIAs) are used to reach previously unvaccinated children. During campaigns, vaccine is generally administered to every child, regardless of their vaccination status and as a result, there is the possibility that a child that is already immune to measles (i.e. who has had 2+ vaccinations) would receive an unnecessary dose, resulting in excess cost. Selective vaccination has been proposed as one solution to this; children who were able to provide documentation of previous vaccination would not be vaccinated repeatedly. While this would result in reduced vaccine and supply cost, it would also require additional staff time and increased social mobilization investment, potentially outweighing the benefits. We utilize Monte Carlo simulation to assess under what conditions a selective vaccination policy would indeed result in net savings. We demonstrate that cost savings are possible in contexts with a high joint probability of an individual child having both 2+ previous measles doses and also an available record. We also find that the magnitude of net cost savings is highly dependent on whether a country is using measles-only or measles-rubella vaccine and on the required skill set of the individual who would review the previous vaccination records.

Optimization of frequency and targeting of measles supplemental immunization activities in Nigeria: A cost-effectiveness analysis.

BACKGROUND: Measles causes significant childhood morbidity in Nigeria. Routine immunization (RI) coverage is around 40% country-wide, with very high levels of spatial heterogeneity (3-86%), with supplemental immunization activities (SIAs) at 2-year or 3-year intervals. We investigated cost savings and burden reduction that could be achieved by adjusting the inter-campaign interval by region. METHODS: We modeled 81 scenarios; permuting SIA calendars of every one, two, or three years in each of four regions of Nigeria (North-west, North-central, North-east, and South). We used an agent-based disease transmission model to estimate the number of measles cases and ingredients-based cost models to estimate RI and SIA costs for each scenario over a 10 year period. RESULTS: Decreasing SIAs to every three years in the North-central and South (regions of above national-average RI coverage) while increasing to every year in either the North-east or North-west (regions of below national-average RI coverage) would avert measles cases (0.4 or 1.4 million, respectively), and save vaccination costs (save $19.4 or $5.4 million, respectively), compared to a base-case of national SIAs every two years. Decreasing SIA frequency to every three years in the South while increasing to every year in the just the North-west, or in all Northern regions would prevent more cases (2.1 or 5.0 million, respectively), but would increase vaccination costs (add $3.5 million or $34.6 million, respectively), for $1.65 or $6.99 per case averted, respectively. CONCLUSIONS: Our modeling shows how increasing SIA frequency in Northern regions, where RI is low and birth rates are high, while decreasing frequency in the South of Nigeria would reduce the number of measles cases with relatively little or no increase in vaccination costs. A national vaccination strategy that incorporates regional SIA targeting in contexts with a high level of sub-national variation would lead to improved health outcomes and/or lower costs.

Cost-effectiveness of measles treatment: a systematic review.

OBJECTIVE: Measles is still common in many developing countries, and its outbreaks have been on the rise since 2009 even though the disease is almost entirely preventable through safe and effective vaccination. This paper aims to provide evidence about the systematic review of the cost-effectiveness of measles treatment in different regions worldwide. METHODS: The methodical search began on 10th January 2019 to look for all articles on the cost-effectiveness of measles treatment published from January 2019 to April 2019 in SCOPUS, Pubmed (www.ncbi.nlm.nih.gov) and Cochrane (www.cochrane.org).We summarised the articles by using a data table to extract all information using health economic evaluation methods. RESULTS: We identified 14 articles from the 69 total articles searched. These articles showed favourable costeffectiveness or cost-benefit ratios in high- and middle-income countries based on data organised by World Bank Income Level in 2018: the United States, Canada, Japan, India and Zambia. However, research is still limited in lowincome countries and thus the effectiveness of vaccination programmes cannot be conclusively identified. CONCLUSIONS: This review shows the overview of the research in health economic evaluations of measles in different places, years and using different methods of intervention. Overall, it evaluates the cost-effectiveness of measles treatment.

Cost-effectiveness of workplace vaccination against measles.

Measles is one of the most contagious infectious diseases. Measles vaccine, which has been introduced in Italy in 1979, is highly effective in preventing the disease (two-dose vaccine effectiveness is 99%). In 2017, Italy was the second country of EU for number of cases of measles. A study conducted in the same year showed that 22.3% of measles infection happened in hospital settings and 6.6% of cases occurred in HCWs. This risk group showed low rates of adhesion to the vaccination campaign. For this reason, we hypothesized that workplace vaccination could lead to better vaccination rates in HCWs. Moreover, we focused the vaccination campaign on a specific target group composed of HCWs not serologically immune and previously not vaccinated. We analyzed the clinical records of measles-specific IgG antibodies of 2,940 HCWs, that underwent occupational health surveillance between 1 January 2017 and 31 December 2017. 15.3% (450) was seronegative for measles, especially in the age group under 35 years. We compared the costs related to strategies with and without serological screening. Our study confirmed that immunization strategy with pre-vaccination screening was cost-effective compared to the vaccination without screening. In our sample, in fact, administration of two dose vaccine only susceptible HCWs determine a saving of 146,262 €. The vaccination of HCWs remains a topical issue in preventing the transmission of infectious disease in the hospital setting. Due to the cost-effectiveness evaluation, we recommend extending the pre-vaccination screening to identify the real susceptible workers.

Differences between coverage of yellow fever vaccine and the first dose of measles-containing vaccine: A desk review of global data sources.

INTRODUCTION: The strategy to Eliminate Yellow Fever Epidemics (EYE) is a global initiative that includes all countries with risk of yellow fever (YF) virus transmission. Of these, 40 countries (27 in Africa and 13 in the Americas) are considered high-risk and targeted for interventions to increase coverage of YF vaccine. Even though the World Health Organization (WHO) recommends that YF vaccine be given concurrently with the first dose of measles-containing vaccine (MCV1) in YF-endemic settings, estimated coverage for MCV1 and YF vaccine have varied widely. The objective of this study was to review global data sources to assess discrepancies in YF vaccine and MCV1 coverage and identify plausible reasons for these discrepancies. METHODS: We conducted a desk review of data from 34 countries (22 in Africa, 12 in Latin America), from 2006 to 2016, with national introduction of YF vaccine and listed as high-risk by the EYE strategy. Data reviewed included procured and administered doses, immunization schedules, routine coverage estimates and reported vaccine stock-outs. In the 30 countries included in the comparitive analysis, differences greater than 3 percentage points between YF vaccine and MCV1 coverage were considered meaningful. RESULTS: In America, there were meaningful differences (7-45%) in coverage of the two vaccines in 6 (67%) of the 9 countries. In Africa, there were meaningful differences (4-27%) in coverage of the two vaccines in 9 (43%) of the 21 countries. Nine countries (26%) reported MVC1 stock-outs while sixteen countries (47%) reported YF vaccine stock-outs for three or more years during 2006-2016. CONCLUSION: In countries reporting significant differences in coverage of the two vaccines, differences may be driven by different target populations and vaccine availability. However,these were not sufficient to completely explain observed differences. Further follow-up is needed to identify possible reasons for differences in coverage rates in several countries where these could not fully be explained.

An economic evaluation of the current measles vaccination program: A case study in Zhejiang Province, east China.

OBJECTIVE: To evaluate the economic impact of the current measles vaccination program in Zhejiang Province, east China. METHODS: A decision tree-Markov model with parameters from published literatures, government documents and surveys was developed and used to simulate over 40 years of a birth cohort in Zhejiang Province during the year 2014. The expected cost and effectiveness of the current measles vaccination program was compared against no vaccination. Costs were assessed from the payer's perspective. Benefits were defined as savings on the direct cost of measles treatment, and the effectiveness was measured according to the number of measles cases and deaths averted. The net present value (NPV), benefit-cost ratio (BCR) and incremental cost-effectiveness ratio (ICER) were also calculated. A threshold for cost-effectiveness of less than 3 times the Gross Domestic Product (GDP) per capita was used. One-way sensitivity analysis was performed to assess parameter uncertainties. RESULTS: The total vaccination cost was estimated to be $2.52 million. The BCR of the current measles program was found to be 6.06 with a NPV of $73.38 million. It was also calculated that a total of 195,165 measles cases and 191 measles-related deaths would be prevented by vaccination. The ICER was approximately $12.91 per case averted and $13,213.43 per death averted, respectively, which was cost-effective. The models were proven to be robust. CONCLUSIONS: The current measles vaccination program appeared to be cost-effective and to offer substantial benefits. The results of this analysis sought to contribute to the justification of future investments to achieve the goal of measles elimination.

Economic value of vaccinating geographically hard-to-reach populations with measles vaccine: A modeling application in Kenya.

BACKGROUND: Since special efforts are necessary to vaccinate people living far from fixed vaccination posts, decision makers are interested in knowing the economic value of such efforts. METHODS: Using our immunization geospatial information system platform and a measles compartment model, we quantified the health and economic value of a 2-dose measles immunization outreach strategy for children <24 months of age in Kenya who are geographically hard-to-reach (i.e., those living outside a specified catchment radius from fixed vaccination posts, which served as a proxy for access to services). FINDINGS: When geographically hard-to-reach children were not vaccinated, there were 1427 total measles cases from 2016 to 2020, resulting in $9.5 million ($3.1-$18.1 million) in direct medical costs and productivity losses and 7504 (3338-12,903) disability-adjusted life years (DALYs). The outreach strategy cost $76 ($23-$142)/DALY averted (compared to no outreach) when 25% of geographically hard-to-reach children received MCV1, $122 ($40-$226)/DALY averted when 50% received MCV1, and $274 ($123-$478)/DALY averted when 100% received MCV1. CONCLUSION: Outreach vaccination among geographically hard-to-reach populations was highly cost-effective in a wide variety of scenarios, offering support for investment in an effective outreach vaccination strategy.

Modeling the economic impact of different vial-opening thresholds for measles-containing vaccines.

INTRODUCTION: The lack of specific policies on how many children must be present at a vaccinating location before a healthcare worker can open a measles-containing vaccine (MCV) - i.e. the vial-opening threshold - has led to inconsistent practices, which can have wide-ranging systems effects. METHODS: Using HERMES-generated simulation models of the routine immunization supply chains of Benin, Mozambique and Niger, we evaluated the impact of different vial-opening thresholds (none, 30% of doses must be used, 60%) and MCV presentations (10-dose, 5-dose) on each supply chain. We linked these outputs to a clinical- and economic-outcomes model which translated the change in vaccine availability to associated infections, medical costs, and DALYs. We calculated the economic impact of each policy from the health system perspective. RESULTS: The vial-opening threshold that maximizes vaccine availability while minimizing costs varies between individual countries. In Benin (median session size = 5), implementing a 30% vial-opening threshold and tailoring distribution of 10-dose and 5-dose MCVs to clinics based on session size is the most cost-effective policy, preventing 671 DALYs ($471/DALY averted) compared to baseline (no threshold, 10-dose MCVs). In Niger (median MCV session size = 9), setting a 60% vial-opening threshold and tailoring MCV presentations is the most cost-effective policy, preventing 2897 DALYs ($16.05/ DALY averted). In Mozambique (median session size = 3), setting a 30% vial-opening threshold using 10-dose MCVs is the only beneficial policy compared to baseline, preventing 3081 DALYs ($85.98/DALY averted). Across all three countries, however, a 30% vial-opening threshold using 10-dose MCVs everywhere is the only MCV threshold that consistently benefits each system compared to baseline. CONCLUSION: While the ideal vial-opening threshold policy for MCV varies by supply chain, implementing a 30% vial-opening threshold for 10-dose MCVs benefits each system by improving overall vaccine availability and reducing associated medical costs and DALYs compared to no threshold.

The value of tailoring vial sizes to populations and locations.

BACKGROUND: Frequently, a country will procure a single vaccine vial size, but the question remains whether tailoring the use of different size vaccine vial presentations based on populations or location characteristics within a single country could provide additional benefits, such as reducing open vial wastage (OVW) or reducing missed vaccination opportunities. METHODS: Using the Highly Extensible Resource for Modeling Supply Chains (HERMES) software, we built a simulation model of the Zambia routine vaccine supply chain. At baseline, we distributed 10-dose Measles-Rubella (MR) vials to all locations, and then distributed 5-dose and 1-dose MR vials to (1) all locations, (2) rural districts, (3) rural health facilities, (4) outreach sites, and (5) locations with average MR session sizes <5 and <10 children. We ran sensitivity on each scenario using MR vial opening thresholds of 0% and 50%, i.e. a healthcare worker opens an MR vaccine for any number of children (0%) or if at least half will be used (50%). RESULTS: Replacing 10-dose MR with 5-dose MR vials everywhere led to the largest reduction in MR OVW, saving 573,892 doses (103,161 doses with the 50% vial opening threshold) and improving MR availability by 1% (9%). This scenario, however, increased cold chain utilization and led to a 1% decrease in availability of other vaccines. Tailoring 5-dose MR vials to rural health facilities or based on average session size reduced cold transport constraints, increased total vaccine availability (+1%) and reduced total cost per dose administered (-$0.01) compared to baseline. CONCLUSIONS: In Zambia, tailoring 5-dose MR vials to rural health facilities or by average session size results in the highest total vaccine availability compared to all other scenarios (regardless of OVT policy) by reducing open vial wastage without increasing cold chain utilization.

Dual-chamber injection device for measles-rubella vaccine: The potential impact of introducing varying sizes of the devices in 3 countries.

INTRODUCTION: By pairing diluent with vaccines, dual-chamber vaccine injection devices simplify the process of reconstituting vaccines before administration and thus decrease associated open vial wastage and adverse events. However, since these devices are larger than current vaccine vials for lyophilized vaccines, manufacturers need guidance as to how the size of these devices may affect vaccine distribution and delivery. METHODS: Using HERMES-generated immunization supply chain models of Benin, Bihar (India), and Mozambique, we replace the routine 10-dose measles-rubella (MR) lyophilized vaccine with single-dose MR dual-chamber injection devices, ranging the volume-per-dose (5.2-26 cm3) and price-per-dose ($0.70, $1.40). RESULTS: At a volume-per-dose of 5.2 cm3, a dual-chamber injection device results in similar vaccine availability, decreased open vial wastage (OVW), and similar total cost per dose administered as compared to baseline in moderately constrained supply chains. Between volumes of 7.5 cm3 and 26 cm3, these devices lead to a reduction in vaccine availability between 1% and 14% due to increases in cold chain storage utilization between 1% and 7% and increases in average peak transport utilization between 2% and 44%. At the highest volume-per-dose, 26 cm3, vaccine availability decreases between 9% and 14%. The total costs per dose administered varied between each scenario, as decreases in vaccine procurement costs were coupled with decreases in doses administered. However, introduction of a dual-chamber injection device only resulted in improved total cost per dose administered for Benin and Mozambique (at 5.2 cm3 and $0.70-per-dose) when the total number of doses administered changed <1% from baseline. CONCLUSION: In 3 different country supply chains, a single-dose MR dual-chamber injection device would need to be no larger than 5.2 cm3 to not significantly impair the flow of other vaccines.

Socioeconomic factors associated with full childhood vaccination in Bangladesh, 2014.

OBJECTIVES: Childhood vaccination in Bangladesh has improved, but there is room for improvement. This study estimated full immunization coverage in Bangladeshi children and characterized risk factors for incomplete immunization. METHODS: Using the 2014 Bangladesh Demographic and Health Survey (DHS), full vaccination of children aged 12 to 24 months was examined; this was defined as the receipt of one dose of bacillus Calmette-Guérin (BCG), three doses of pentavalent vaccine, three doses of oral polio vaccine (OPV), and one dose of measles-containing vaccine (MCV). Associations between full vaccination and selected risk factors were assessed by logistic regression. RESULTS: Overall, 83% of children were fully vaccinated. BCG had the highest completion (97%), followed by OPV (92%), pentavalent vaccine (91%), and MCV (85%). Full vaccination coverage ranged from 64.4% in Sylhet to 90.0% in Rangpur and was lowest among non-locals of all regions (78.4%). Children who were in the lowest wealth quintile, who had mothers without antenatal care visits, or who had mothers without autonomy in healthcare decision-making were less likely to be fully vaccinated. CONCLUSIONS: Overall, full vaccination of children is high, but varies by vaccine type. Disparities still exist by wealth and by region. Maternal access to care and autonomy in healthcare decision-making are associated with higher vaccination coverage.

Vaccine wastage in Nigeria: An assessment of wastage rates and related vaccinator knowledge, attitudes and practices.

INTRODUCTION: The introduction of new vaccines highlights concerns about high vaccine wastage, knowledge of wastage policies and quality of stock management. However, an emphasis on minimizing wastage rates may cause confusion when recommendations are also being made to reduce missed opportunities to routinely vaccinate children. This concern is most relevant for lyophilized vaccines without preservatives [e.g. measles-containing vaccine (MCV)], which can be used for a limited time once reconstituted. METHODS: We sampled 54 health facilities within 11 local government areas (LGAs) in Nigeria and surveyed health sector personnel regarding routine vaccine usage and wastage-related knowledge and practices, conducted facility exit interviews with caregivers of children about missed opportunities for routine vaccination, and abstracted vaccine stock records and vaccination session data over a 6-month period to calculate wastage rates and vaccine vial usage patterns. RESULTS: Nearly half of facilities had incomplete vaccine stock data for calculating wastage rates. Among facilities with sufficient data, mean monthly facility-level wastage rates were between 18 and 35% across all reviewed vaccines, with little difference between lyophilized and liquid vaccines. Most (98%) vaccinators believed high wastage led to recent vaccine stockouts, yet only 55% were familiar with the multi-dose vial policy for minimizing wastage. On average, vaccinators reported that a minimum of six children must be present prior to opening a 10-dose MCV vial. Third dose of diphtheria-tetanus-pertussis vaccine (DTP3) was administered in 84% of sessions and MCV in 63%; however, the number of MCV and DTP3 doses administered were similar indicating the number of children vaccinated with DTP3 and MCV were similar despite less frequent MCV vaccination opportunities. Among caregivers, 30% reported being turned away for vaccination at least once; 53% of these children had not yet received the missed dose. DISCUSSION: Our findings show inadequate implementation of vaccine management guidelines, missed opportunities to vaccinate, and lyophilized vaccine wastage rates below expected rates. Missed opportunities for vaccination may occur due to how the health system's contradicting policies may force health workers to prioritize reduced wastage rates over vaccine administration, particularly for multi-dose vials.