Children pay the price

What do we truly value as a society? Right now, 95% of the world’s population has basic mobile phone coverage. 1 This is a great achievement in terms of global development, but surely we expect the same for life-saving vaccines?
Sadly, this is not the case.

Coverage of a third dose of vaccine protecting against diphtheria, tetanus, and pertussis (DTPcv-3) remained at 86% in 2018. While immunization is probably the most successful public health intervention, reaching 86% of infants is not enough. 2

We can and must do better.

Under-immunization and lack of access to vaccines remain critical challenges – and children in the world’s most fragile, vulnerable societies are the hardest hit.

  • Pneumococcal conjugate vaccine. This has the potential to significantly reduce deaths in children under the age of 5, yet global coverage has yet to reach 50 percent.3
  • Measles vaccine. Two doses of the measles vaccine are required to prevent the disease and the illnesses, disabilities and deaths caused by complications associated with it. Coverage with the second dose of measles vaccine increased from 59 per cent in 2015 to 67 per cent in 2017, but that is still insufficient to prevent this highly contagious disease.4




Whether it’s mountains or militias, it is always remote, fragile, frequently war-torn countries that are likely to have poor vaccine coverage and higher rates of under-immunization. And it is children in these fragile countries who are the hardest hit by poor vaccine coverage.

Children in fragile settings are being left behind. Vaccination coverage in fragile countries is almost 10% lower than in non-fragile countries.5 Given the acute problems and rapid population growth of fragile countries, simply maintaining existing vaccine coverage is a real challenge. GAVI informs us6

  • 13.5 million children lack access to vaccination services
  • Just 10 countries account for 60% of unprotected children
  • Un-and under-vaccinated children disproportionally live in fragile countries
  • Almost half of the un-and under vaccinated live in the African Region

“War is the perfect environment for disease to spread. With many hospitals and clinics in Yemen bombed or abandoned, it’s estimated one child dies every ten minutes from a vaccine-preventable disease.”

7 UNICEF, Progress and Challenges with Achieving Universal Immunization.

10 countries account for 60% of unprotected children


Just 10 countries account for 60% of unprotected children
Presently, almost half the world’s un- and under-vaccinated people live in the African region – exactly where today’s Cold Chain supply infrastructure is the most difficult to maintain and manage.


  • 1-in-5 children worldwide still fail to receive even basic vaccines 9
  • 1.5 million children die every year from vaccine-preventable diseases 10
  • 20 million children are dangerously under-vaccinated 11
  • 30% of deaths among under 5-year-olds are from vaccine-preventable causes 12

Despite powerful calls and increased activity from global health organizations and
policymakers, vaccination coverage in many areas remains stubbornly low:



  • DIPHTHERIA, TETANUS AND PERTUSSIS vaccine coverage for these vaccines remained unchanged between 2015 and 2017; an estimated 19.9 million children have not received the vaccine during the first year of life. 13
  • PNEUMOCOCCAL CONJUGATE vaccine, which has the potential to significantly reduce deaths in under 5-year-olds, is still to reach 50 percent. 14
  • MEASLES 140,000 people died from measles in 2018 in devastating outbreaks in all regions. Most deaths were among children under 5 years of age. 15
  • HPV (HUMAN PAPILLOMAVIRUS) is known to reduce cervical cancer by 51% among girls aged 15–19, 16 yet only 14 of Africa’s 54 countries have national HPV vaccination programs. 17

The vaccine need is further challenged by climate change and civil conflict, increasing the risk of diseases and putting the lives of the most vulnerable at risk.


And at the heart of these challenges, time and again, is the constant challenge to transport fragile, liquid vaccines to fragile precarious countries at robustly, strictly controlled refrigerated temperatures. The regions that most need vaccines are many of the most precarious in the world. Yet, vaccines in their present liquid solution form need strict, constant temperature control – to reach areas where maintaining this is virtually impossible.

Today’s liquid vaccines require unbroken refrigeration and electricity supply – yet in the world’s poorest, most fragile countries, those that need vaccines most, temperatures are rising, only 10% have a reliable electricity supply and half of healthcare facilities have no electricity supply at all.

Little wonder that for the hard-pressed nurses and medics in those countries, the Cold Chain presents as many problems as it does benefits:



From Guinea to the Democratic Republic of Congo: what’s it like to immunize children in tropical heat and fragile, precarious conditions – whilst battling to keep vaccines refrigerated?

In 2014 Médecins Sans Frontières asked nurses, doctors and logistics experts just that. In a detailed report named Vaccinating children beyond the ‘cold chain’ 18  here’s what they said:

“Shipping and storing vaccines in a ‘cold chain’ in the tropical heat of many resource-limited countries – whereby the vaccine is kept at temperatures between 2°C to 8°C from the point of manufacture until reaching the recipient – is a tremendous challenge and a major cause of poor immunisation coverage rates”

MSF, Médecins Sans Frontières

“It’s a nightmare. At the base, where we hold our stock, we have 17 fridges full of the vaccines. We also have the 17 freezers to make and store the 5,000 ice packs we need. The ice packs go into a big cold box which is taken out to the vaccination sites. But even there, we then have to transfer the vaccines from the big cold box, into smaller cold boxes, because at each single stage we have to protect the vaccines
so that they remain effective.”

Sophie Dunkley, Epidemiologist, MDF measles vaccination campaign, Guinea, february 2014

Map vector created by freepik – www.freepik.com

“In many places, you can often arrive at a health center – a place that should be buzzing with children – to find it is totally empty, no staff or anything. You understand why when you see that the fridge to store the vaccines is broken and no child has been vaccinated in months.”

Dina Hovland, MSF Nurse and Midwife

“The closer to the patient, the more critical transport can become. In the Democratic Republic of Congo, for example, large cold boxes are hand-carried over rough paths which sometimes need to be cleared of vegetation, or include river crossings, in order to reach the vaccination sites.”

Malcolm Townsend, MSF Cold Chain Logistician

“We spend hundreds of thousands of euros each year just on the equipment alone – the fridges, the freezers, the monitoring tools that we need in order to make sure that these vaccines stay effective.”

Malcolm Townsend, MSF Cold Chain Logistics



As the MSF study showed, a disproportionately large amount of the total financial cost of vaccines goes on maintaining the Cold Chain too – so the overall cost of vaccines per person remains significantly higher than wished for.

The cold chain: There are many stages of vaccine manufacture,
storage and transport where refrigeration has to be maintained.

In 2016 the WHO’s Global Ebola Vaccine Implementation Team (GEVIT) released a detailed breakdown of costs for an Ebola vaccination campaign that had inoculated 24,875 people. 19 In the document the total cost of the entire West Africa Ebola outbreak was 53.2 USD (billion). The WHO GEVIT analysis shows that one third of vaccine costs went solely to the Cold Chain:


  • Cost of vaccine per person: 135 USD
  • Cost of Cold Chain as proportion of overall costs: 1.09 of 3.38 USD (million) – almost 1/3

If Cold Chain costs had been eliminated, the overall cost of the West Africa Ebola inoculation campaign could have been reduced by 17.5 USD (billion) through eliminating Cold Chain costs and using dry powder vaccines instead.

  • 53.2 USD (billion): Total cost of West Africa Ebola campaign incl. Cold Chain
  • 35.7 USD (billion): Cost without Cold Chain

With the Cold Chain requiring such high administration, management and electricity costs – almost a third of total vaccination program costs – being able to eliminate Cold Chain spending would be a major step in reducing costs and complexity – and increasing control and coverage.




In a WHO vaccination pilot project in Benin that delivered vaccines outside the Cold Chain at ambient temperatures (up to +40o C) for the first time, the WHO found overall costs could be cut but by a half. 20

“Findings show that it is possible to deliver vaccines more conveniently and at a lower cost when refrigeration is not needed every step of the way,” said Dr. David C. Kaslow, vice president of product development at PATH.


The Benin Pilot Project used a “Controlled Temperature Chain” (CTC) that vaccinated 155,000 people across 150 villages achieving a 106 percent administrative coverage rate. Following the project, in 2013, no cases of meningitis A were reported across Benin, including the area where the vaccine wasn’t kept cold.

Vaccinating teams were enormously positive as the CTC vaccines allowed them to vaccinate more people per day, and meant they didn’t need to return from far-away villages to the health centers each night to continuously freeze ice packs. They also appreciated the reduced weight of the vaccine bagss. Overall, 100 percent of vaccinators and 99 percent of supervisors said they preferred CTC to the traditional cold chain.

Map of Africa / Benin

Map vector created by freepik – www.freepik.com

“This flexibility makes it easier for vaccinators to reach ‘the last mile,’ from the health center to the child, ensuring that we reach and protect all people at risk, even those in remote areas and not just those that can be accessed by a cold chain,” said study author Simona Zipursky.

But again, there is a problem. Few vaccines, despite WHO interventions, can survive for four days without refrigeration – as was the case with the Benin pilot. High temperatures or a fall in temperature below zero for freeze-sensitive vaccines can cause vaccines to lose their potency, and once a vaccine loses its potency it cannot be restored and may if used later cause an immunological reaction.



But challenges with the Cold Chain continue. Not only are human and financial  resources lost with the Cold Chain – much of the vaccines themselves, some of the simplest yet most sophisticated substances ever created by science, are lost too.

The WHO estimates that more than 50% of vaccines may be wasted globally every year because of temperature control, logistics and shipment-related issues. 21

Wastage in unopened vials is usually attributable to cold chain and stock management problems and can be minimized. Bad management is a primary cause of unopened vials being discarded because of expiry and heat exposure and freezing in the cold chain. It is essential to minimize these factors. Cold chain failures may expose vaccines to high temperatures if storekeepers and/or health workers do not know what to do in such cases.

Such wasted vaccines mean wasted money, and for the people who never receive the vaccines, potential suffering and even loss of life.


  1. International Telecommunications Union (ITU), the UN’s specialized agency on technology. https://www.itu.int/en/ITU-D/Statistics/Documents/facts/ICTFactsFigures2015.pdf
  2. Progress and Challenges with Achieving Universal Immunization Coverage
    2018 WHO/UNICEF Estimates of National Immunization Coverage (Data as of July 2019)
  3. https://sustainabledevelopment.un.org/sdg3
  4. https://sustainabledevelopment.un.org/sdg3
  5. https://www.gavi.org/sites/default/files/publications/2021-2025%20Gavi%20Investment%20Opportunity.pdf
  6. https://www.gavi.org/sites/default/files/publications/2021-2025%20Gavi%20Investment%20Opportunity.pdf
  7. https://www.unicef.org.au/blog/unicef-in-action/april-2017/photos-vaccines-reach-most-remote-places-earth?fbclid=IwAR1t_KCdts3D2WI0uy54vYt-bBZ03-rqNREXSqG63bw-nTe7lp27OH_-H5g
  8. https://www.who.int/immunization/monitoring_surveillance/who-immuniz.pdf?ua=1
  9. https://www.weforum.org/agenda/2018/07/the-biggest-hurdle-to-universal-vaccination-might-just-be-a-fridge
  10. https://www.unicef.org/immunization
  11. https://www.who.int/news-room/detail/15-07-2019-20-million-children-miss-out-on-lifesaving-measles-diphtheria-and-tetanus-vaccines-in-2018
  12. https://www.unicef.org/immunization
  13. https://sustainabledevelopment.un.org/sdg3
  14. https://sustainabledevelopment.un.org/sdg3
  15. https://www.who.int/news-room/detail/05-12-2019-more-than-140-000-die-from-measles-as-cases-surge-worldwide
  16. Drolet M, Bénard É, Pérez N, Brisson M; HPV Vaccination Impact Study Group. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes:
    updated systematic review and meta-analysis. Lancet. 2019;394(10197):497–509
  17. https://jamanetwork.com/journals/jama/article-abstract/2755625
  18. https://www.msf.org/sites/msf.org/files/msf_access_issuebrief_thermostability_en.pdf
  19. https://www.who.int/csr/resources/publications/ebola/GEVIT_guidance_AppendixK.pdf?ua=1
  20. https://www.who.int/immunization/newsroom/press/19_02_2014_meningitis_vaccine_outside_cold_chain/en
  21. https://apps.who.int/iris/bitstream/handle/10665/68463/WHO_VB_03.18.Rev.1_eng.pdf?sequence=1&isAllowed=y