Asked which vaccines they would most like to see licensed for CTC use, most vaccinators and supervisors cited other vaccines used in campaigns, with polio (44%), measles (40% and yellow

HIF-1 pathway fever (29%) the most commonly cited. Over the course of the campaign, 155,000 people were vaccinated with MenAfriVac in a CTC. This marks the first time since the establishment of EPI that a campaign was conducted using a vaccine with on-label guidance for use beyond the 2–8 °C standard cold chain range. As per the coverage rates attained, the campaign was successful in reaching the target population. The 2013 disease surveillance across Benin—including in the CTC area—supports this, with no cases of Meningitis A reported in the vaccinated population [9]. Cold chain has been a limiting factor since the inception of the EPI. The need to keep vaccines between 2 and 8 °C at all times currently drives the way immunization strategies are developed and implemented. This study provides a first example of the types

of benefits that could be seen from removing that constraint, especially for immunization campaigns and other outreach based strategies. While the rigorous regulatory reviews provided assurance as to the efficacy of the vaccine, the pilot provides critical validation of the acceptability of the practice by health care workers. In addition to the survey results which indicated a strong preference for CTC when feasible, the CTC approach also has the potential to have a positive impact on the provision of

other primary health care initiatives, freeing up health care worker time and resources to check details keep other regular primary care services operational (often cancelled during Non-specific serine/threonine protein kinase campaigns) [10], rather than managing cold chain and ice pack production logistics [11]. In addition, while the original six EPI vaccines were very sensitive to heat, many new vaccines—including the MenAfriVac diluent—are damaged by exposures to freezing temperatures while remaining stable at higher temperatures for longer periods of time. Studies have shown that freezing is a particular risk during transport and outreach [12]. The CTC practice removes the risk of freezing during these activities at the ‘last mile’. As with any new practice, there were several challenges noted with the CTC implementation. The biggest of these was the need to discard unused vials after four days in a CTC, rather than having the ability to return them to the fridge. This required close supervision by health care workers and district health staff, and if staff are not well trained, could lead to increases in vaccine wastage. Once trained, vaccinators found the peak threshold temperature cards easy to use. However the need to ensure the vaccines are always kept with an indicator provides an additional difficulty, and vial level peak threshold indicators should be considered. Caution must be exercised around storage of the indicator cards prior to use.