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This forum provides a place for members to ask questions, share experiences, coordinate activities, and discuss recent developments in immunization.
  1. David Brown
  2. Supply chain and logistics
  3. Friday, October 28 2016, 01:08 AM

Posting by:

David W Brown, Brown Consulting Group International, LLC, North Carolina, USA

Marta Gacic-Dobo, World Health Organization, Geneva, Switzerland

The WHO and UNICEF recommend that immunization programmes order and supply vaccines bundled with safe-injection equipment (e.g., diluents, auto-disable syringes, reconstitution syringes and safety boxes) to better ensure that AD syringes along with other safe-injection equipment are available together with vaccines in appropriate corresponding quantities at the point of delivery, thereby promoting overall safe injection practice [1]. Overall, the use of bundling vaccines with safe-injection equipment appears to be a success story.

As children receive recommended immunization services necessary to be protected from vaccine-preventable diseases, it is important for healthcare workers to deliver and caregivers to keep legibly completed records of the vaccinations that the child receives, particularly given recent increases in the number of vaccinations in recommended immunization schedules and mixed results of caregiver’s ability to accurately recall their child’s vaccination history.

Home-based records (HBRs) (e.g., vaccination card, maternal/child health book) are used by health authorities alongside facility-based records, to document an individual’s vaccination history (as well as other primary care services in some countries) and as a communication and information resource to encourage a partnership in the care of the child between the healthcare worker and the caregiver. Not only do HBRs serve as a vehicle for health education to empower caregivers about which primary healthcare services have been received and those which remain outstanding, HBRs (when available and complete), also enhance health professionals’ ability to make appropriate clinical decisions (e.g., which vaccinations have been received already and which vaccinations remain outstanding) and improve continuity of care across providers in the absence of other health records and support public health monitoring efforts, such as in vaccination coverage surveys [2].

However, HBRs are currently unable to fulfil their intended purpose in many communities either because the HBR is not functionally well-designed to serve the needs above, not made available, not fully adopted and/or not appropriately utilized by caregivers and/or health workers. Of particular concern are the occurrence of HBR stock-outs in many countries.

According to data reported by national immunization programmes to the WHO and UNICEF, of the more than 140.2 million estimated births during 2015, roughly 9% or estimated 12.4 million children were born in 22 countries reporting a national level HBR stock-out that year. Two-thirds (or 8.3 million) of these children resided in one of 12 countries in the WHO African Region, and more than half (4.8 million) of these children resided in the Democratic Republic of Congo or Kenya. DRC along with Chad, Guinea Bissau and Venezuela has reported HBR stock-outs during 2013, 2014 and 2015. Other countries with large (>500,000) birth cohorts reporting national level stock-outs during 2015 included Philippines, Ghana, Cameroon, Malawi, Chad and Venezuela (overall, five countries reporting HBR stock-outs were from the Western Pacific Region, three from the Region of the Americas and one each from the Eastern Mediterranean and South-East Asia Regions). Two-thirds of the countries reporting HBR stock-outs during 2015 were Gavi-eligible. Information on HBR stock-outs was either not available or not reported by 53 (11 were Gavi-eligible) countries for 2015.

These HBR stock-outs are quietly occurring against a back-drop of increased attention to the immunization supply chain [3,4] and need to improve availability and use of data for decision making at all levels of the immunization programme. Unfortunately, there appears to be little attention towards exploring the root causes for why these HBR stock-outs are occurring and what practical steps can be taken to prevent them. Make no mistake, each and every one of these HBR stock-outs — not unlike stock-outs of vaccines — is an avoidable event with proper planning.

So, similar to the initial proposal for bundling AD syringes with vaccines, we propose further exploration and consideration of the bundling concept for HBRs to better ensure that HBRs are available at the point of delivery for recording of vaccines delivered. We have previously posted to TechNet to get feedback from our colleagues with expertise in market shaping for vaccines and safe-injection equipment. We reach out again to our colleagues in immunization supply chain to solicit feedback on the feasibility of implementing a bundling policy inclusive of HBRs alongside the vaccines and safe-injection equipment. We see potential benefits, but we also realize that there may be risks and practical challenges, all of which we hope to identify, understand and address. We look forward to learning from our logistician colleagues and your responses!


1. World Health Organization. Training for mid-level managers (MLM). Module 1. Cold chain, vaccines and safe-injection equipment management. Geneva, Switzerland: World Health Organization, 2008. Available online at Accessed 21 October 2016.

2. World Health Organization. Practical Guide for Home-based Records in Immunization Programmes. Geneva, Switzerland: World Health Organization, 2015. Available online at . Accessed 21 October 2016.

3. UNICEF. Immunization Supply Chain Strengthening. October 2015. Available online at . Accessed 21 October 2016.

4. Gavi, the Vaccine Alliance. Gavi Immunization Supply Chain Strategy. Available online at . Accessed 21 October 2016.

David Brown Accepted Answer

Dear Friends and Colleagues,

Please find a manuscript following on the initial posting on home-based record stock-outs at the following link:

We hope this discussion on the challenges of ensuring that home-based records are available in the right place, at the right time and in the right quantity continues in countries and among partners.


  1. more than a month ago
  2. Supply chain and logistics
  3. # 1

Thanks for this stimulating discussion.

I totally agree with the rationale behind HBR; certainly, a family has the right (and the responsibility) of keeping records of what has been done to their children, and to other family members. At least, this has to be promoted and offered to them.

An appealing option is to link PSM of medical products to that of HBR. This could be estimated following the calculations for vaccine birth-doses, since birth is the ideal moment when a HBR is delivered and started to be filled in.

Another option could be to link it with procurement of paper forms, on the grounds of the potential similarity of underlying causes of stock out of forms and HBR; and on the obvious similarity of these products and the technology to produce them. I did not check this thoroughly, but there is certainly anecdotal evidence of stock outs of all sort of forms in health facilities which are often substituted by hand-made forms. Local production (and hand-made is an extreme example of local production) could also be considered. We are exploring some these issue in PHISICC ( although I don't think we will be able to address the issue of HBR specifically.

By the way, I like the point made by Nassor in using health facility records to track batch numbers when required.

Xavier Bosch-Capblanch

  1. more than a month ago
  2. Supply chain and logistics
  3. # 2
nassor Accepted Answer

Hi Collegues,

While thinking of adding additional data entry into the HBR we should think twice and ask ourselves on the experiences of filling the existing data entry parts in the existing HBR (without batch numbers). Based on my experince from Tanzania, we do not record the batch numbers in the HBR but still the filling of the HBR tool is not 100% completed, I am worried adding additional data entry especially the batch numbers which is somehow long and need concentration during recording. Before accepting the idea of adding space for recordig the batch numbers in the HBR we should ask ourselves several question, my understanding if the SoP for vaccine management is well followed we do not expect to have more than two batch numbers at the point of vaccination. If that is the case then, Vaccine ledgers/vaccine stock records at the facility level is surfice to have information on batch numbers when needed for AEFI surveillance. The idea of having space to recrds batch number is not bad but I am not sure if we have enough justification for that interms of adding values since we have that information in the stock ledgers but also we need to have assuarence that the information will be filled and filled correctly for it to serve the purpose. Lets take a look at different vaccine vials and see how difficult to read those batch numbers and record to the HBR. The aim might be good but I am worried if that is going to add value.



  1. more than a month ago
  2. Supply chain and logistics
  3. # 3
David Brown Accepted Answer


I appreciate the thoughts. We need more inputs like this from colleagues.

In fact, the recording of batch numbers for vaccines and diluents on HBRs across countries is far from universal. My experience suggests that very few countries in Africa and South East Asia currently maintain policy that would require this practice and in many cases the HBRs are not designed to facilitate doing so; there is no designated space for recording these items. We also recommend that there be a signature or initialization of the date of service by the health worker delivering the vaccine, but this too is not universal. While I agree that this might facilitate AEFI follow-up, current practice is lagging. I would like to have some countries share their experiences if they have tried to incorporate batch numbers recording fields. If there are countries where health workers are encouraged/required to record batch #'s, how well are these fields completed by health workers?

Similar to differences in wastage levels for vaccines and AD syringe wastage levels, quantities of HBRs will differ from the number of vaccines and AD syringes in the bundle. Certainly when programmes consider issues around the right stock of HBRs, the unit changes from per dose to per child, which should not be problematic since one approach to vaccine forecasting utilizes the annual birth cohort / target population as a starting point. We would like to explore the opportunity.

My experience also suggests that bundling HBRs to other management tools has largely been ineffective and we need to understand why in case there are improvements that can be made along those avenues too.

We also recognize that if HBRs are procured (meaning ordered, printed and other pre-distribution activity) either by multiple departments or departments different than the immunization programme or programme responsible for supply chain management of vaccines and safe-injection equipment, then close communication and coordination must be ensured so that the correct number of HBRs is ordered, printed and available for distribution in the vaccine bundle. Challenges with complex HBR financing arrangements must also be addressed. We would very much like to learn from country colleagues about how they currently handle these complexities, both the examples of perceived good practice as well as from those where they recognize the current system is falling short.

On the issue of distribution of campaign-specific cards, I agree that this can create confusion. The preferred choice is for all vaccines, regardless of whether delivered through routine or campaigns, to be recorded in the child’s HBR. Ideally there the HBR will be designed with additional spaces for recording campaign doses and doses of new vaccines received prior to revised HBRs to be produced and distributed. In those countries where campaign specific cards continue to be the norm, we would very much like to learn if there are any unique HBR designs that might include pockets at the back of the document where these campaign cards could be kept safe or other design options.


  1. more than a month ago
  2. Supply chain and logistics
  3. # 4
Gaël du Chatellier Accepted Answer

Hi David,

Thanks for this interesting paper and idea.

I would like to add that HBR are not only needed to link caregivers with health workers. It's also very important for the follow up of Adverse Events Following Immunization (AEFI). Health workers are required to write down the batch number for the vaccine AND the diluent for tracking purpose.

About the idea of bundling HBR with the vaccine and safe-injection equipment, I acknowledge the importance of securing the right stock of HBR but practically I cannot see how we could operationalise this as the quantity needed for HBR for a dose of vaccine is not known. We can pair the number of safety boxes, diluent, dilution syringes, etc. to a dose but one HBR for one dose of vaccine is not right as supposedly the child should have all the vaccine history on one single HBR.

Eventually what could be done is to evaluate the rough HBR consumption and distribute let say 10 HBR for 100 doses. But we will then need to make sure that the stock of HBR is available at central level which is not always the case. The habit as HBR are concerned is often to produce them once in a while and to push them to the points of service regardless the remaining stock.

Another way to address the lack of HBR at the points of services would be to bundle HBR with the management tools (stock cards, tally sheets, temperature chart, etc.) and then to address in the meantime their constant stock out. A specific procedure could be added to the national SOP for vaccine management to prepare twice a year a parcel with all the required equipment for vaccination (HBR + management tools) and push them to service points.

We have tested this idea during a MenaFrivac mass vaccination campaign in Cameroon. It worked globally well as we had all the supply from manufacturers and forms from publishers well in advance but the challenges that we face were 1) to make sure that the workers at the warehouse were putting the right quantities in the parcels according to the target population and 2) to make sure that parcels were clearly marked to reach the right district instead of another of a different size.

Speaking about vaccination campaigns, another issue for HBR that comes with SIAs is that we often distribute specific vaccination cards (Yellow Fever for example) which leads to confusion for the caregivers who would not know which one to keep and to take when going for medical care.

Happy to discuss more if needed.

Have a nice day.

  1. more than a month ago
  2. Supply chain and logistics
  3. # 5

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