IQVIA

WhitePaper

TipoftheIceberg:Economic

andEnvironmentalImpactoftheVaccineColdChain

WhitepapercommissionedbyStablepharma

STEFANLUTZMAYER,SeniorConsultant,EMEAThoughtLeadership,IQVIAELINAOSOIANU,Consultant,StrategyConsulting,IQVIA

TOMROSENFELD,BusinessDevelopmentManager,Stablepharma

Tableofcontents

Introduction1

Hiddendifficultiesincoldchainmanagement1

Temperatureexcursions2

Implicationsofcoldchainfailure3

Towardssustainablesolutions3

Methodology5

Transportation6

Storage7

Wastage7

Environmentalimpactcalculation8

EstimatingeconomicandenvironmentalimpactofvaccineadministrationinEurope8

Results8

Thecoldchainhasasignificanteconomicimpact8

Economiccostcomparisonofcoldchainvs.thermostablevaccines9

Coldchainvaccinecostcomparisonfordifferentvaccinetypes11

Environmentalimpact12

Conclusion13

References14

Abouttheauthors16

Introduction

Vaccinesareundoubtedlyamongthemosteffectivehealthcareinnovationsofthe20thcentury,withanestimated154millionlivessavedtodateasaresultofglobalimmunisationprogrammes1.Therapid

developmentandmassvaccinationcampaignsseenduringtheCOVID-19pandemicwereacaseinpoint.Inthe21stcentury,modernvaccinetechnologies

pushtheboundariesofwhatispossibleintermsof

speedofdevelopment,butmajorchallengesremain

inthemanagementofthecoldchainbetweenthe

pointofvaccinemanufactureandthepointofvaccine

administrationtopatient,regardlessoflocation.Whilstweallremembertherequirementsforhospitalsto

procurelargeultra-lowtemperaturefreezersforthe

storageofsomeCOVID-19vaccines,itistruethat

refrigeratedorfrozenstorageisneededforallvaccinesadministeredacrosstheglobe.Therelianceonthe

pharmaceuticalcoldchainaddssignificantcomplexitytoanalreadyconvolutednetworkofdifferentstakeholdersworkingtogethertoensurethemaintenanceof

temperaturecontrolalongthesupplychain.This

additionalbarrieriswell-recognisedinLowandMiddle-IncomeCountries(LMICs)duetopoorinfrastructure.

However,theconsiderableimpactofthevaccinecold

chaininhigh-incomecountriesincludingEuropeandtheUnitedStatesisoftenunderappreciated.

Inthiswhitepaper,wepresentanevidence-based

approachtounderstandingtheeconomicand

environmentalimpactsofthevaccinecoldchainin

Europe,focusingontheUK,GermanyandSpain,and

providein-depthanalysesontherespectivecontributionsoftransportation,storage,andwastemanagement.

Hiddendifficultiesincoldchainmanagement

Thepharmaceuticalcoldchainencompasses

theentiresupplychainwithanuninterrupted

temperaturecontrolusingcoldrooms,shippingcontainers,refrigerators,andvehiclestomaintaintheintegrityandefficacyofbiologicalmedicines,includingvaccines2,3.

Mostvaccinesrequireconstantrefrigerationbetween2-8°C,whilstsomebiologicsmustbestoredat-20°C,andcertainmRNAvaccinesnecessitateUltra-Low

Temperatures(ULT)aslowas-80°C.

Stricttemperaturecontroliscrucial,asmostvaccinescontaintoxoid-basedproteinantigensthatrequire

precisestructuralintegritytoelicitaneffective

immuneresponse.Exposuretoelevatedtemperaturescancausetheseproteinstounfold,aggregate,and

degrade4,whereasfreezingtemperaturescanresultintheformationoficecrystals5,disruptingtheproteinstructureandleadingtoirreversibledenaturation.

Beyondantigenstability,adjuvantssuchas

aluminiumsaltsplayakeyroleinenhancing

immuneresponsesbypromotingantigen-presentingcellsactivationandproliferation.Storageoutside

thespecifictemperaturerecommendations(typically2-8°C)candrasticallyalterthephysicochemical

propertiesofanadjuvant,resultinginalossof

immunogenicityandrenderingvaccinessub-potent.

Thepharmaceuticalcoldchain

encompassestheentiresupplychainwithanuninterruptedtemperaturecontrolusingcoldrooms,shippingcontainers,refrigerators,and

vehiclestomaintaintheintegrity

andefficacyofbiologicalmedicines,includingvaccines.

Vaccinesconstituteasubstantialportionofthe

globalcoldchainvolume,withapproximatelyfive

billiondosesadministeredannually6.Thelogisticalchallengesofvaccinecoldchainmanagementariseduetotheexpansivesupplynetworkthattypicallyincorporatesmultipleintermediarypoints,suchasregionaldistributioncentresandbiopharmaceuticalwholesalers(Figure1).Thiscomplexityisfurther

compoundedbyrigorousregulatoryguidelinesandvaccine-specificstorageandhandlingrequirements.Whileextensiveefforts—includingrobust

temperaturemonitoringsystems,infrastructureimprovementsandcomprehensivetraining

havebeenimplemented,temperatureexcursions

remainaconsiderablechallengeinglobalcoldchainmanagement,withtheseincidentstakingplaceacrosshigher-,middle-,andlower-incomecountries.

|1

Figure1:Vaccinesupplychain—illustrative

Vaccination

centres

National

warehouse

Longdistancetransport

WholesalersHospitals/carehomes

EU

warehouse

Regional

warehouse

WholesalersPharmaciesPCPs

(PrimaryCareProviders)

Source:IQVIAEMEAThoughtLeadership;Kurzweiletal.(2021)

Themanagement,maintenance,andinvestment

inthepharmaceuticalcoldchainrepresentsa

substantialeconomiccostduetoboththecapitalexpenditureandoperatingcostsrelatingtocold

chaininfrastructure,withUNICEFaloneprocuring$105.9millionofcoldchainequipmentandservicesin20237.AccordingtoIQVIA,theglobalcold

chainmarketaccountedfor38%marketshare

ofallpharmaceuticals,upfrom26%in2017,and

expenditureoncoldchainlogisticswasestimatedtobearound$21.3billionin20248,9.

Temperatureexcursions

Temperatureexcursions—instanceswherevaccinesarestoredoutsidethestipulatedstoragetemperaturerequirements—mayresultinsub-potentor

entirelynon-potentvaccines.Consequently,thesevaccinesfailtoprovideadequateprotectionagainsttargeteddiseases.

Temperatureexcursionstypicallyariseduetoa

combinationofhumanerror,equipmentfailure,

andlogisticalchallenges.Acommoncauseof

temperatureexcursionsistheuseofstorageand

transportationpracticeswhichexposevaccinesto

33%

freezingtemperatures.Freezingtypicallyoccursduetoanoveremphasisonheatprotection,drivenbythemisconceptionthatvaccinesaremoresusceptibleto

damagefromheatthanfreezing.Thismayleadtotheexcessiveuseoficepacksduringtransportationofvaccineswhichrequirestorageat2-8°C.

Furthermore,theuseofnon-medical-grade

refrigeratorsmaycausetemperaturefluctuationsandnon-uniformcooling,resultinginthefreezingofsomeorallofthefridgecontents.Indeed,a2017literaturereviewoffreezingwithinthecoldchain,spanning

bothhigher-andlower-incomecountries,suggested

thatfreezingofvaccinesremainsawidespreadissue10.Vaccinestoragedataindicatedthatexposureto

temperaturesbelowtherecommendguidelineswereobservedin33%and37%ofhigher-andlower-incomecountriesrespectively.Similarly,vaccinetransportationdataindicatedthatexposuretotemperaturesbelow

thoserecommendedoccurredacrossstudiesin38%ofhigher-incomeandin19%oflower-incomecountries.

Itisalsowellknownthatvaccineexposuretoexcessiveheatcanresultfrommechanicalfailureofcold-storageunitsaswellaspoweroutages.Theseissuesare

exacerbatedinlower-incomecountrieswherecold

chaininfrastructureisoftenlessreliable,andpower

outagesaremorefrequent.However,humanerror

—suchasinadequatetemperaturemonitoringand

impropervaccinehandlingduringtransport—remainsakeycontributingfactortotemperatureexcursions

throughoutthecoldchain.

Vaccinestoragedataindicatedthatexposureto

temperaturesbelowtherecommendedguidelineswasobservedinhigher-incomecountriesatarateof33%.

2|TipoftheIceberg:EconomicandEnvironmentalImpactoftheVaccineColdChain

|3

Implicationsofcoldchainfailure

Regulatorybodies—forexampletheUKMHRA—

providedetailedguidanceonincidentsrelatingtoerrorsinvaccinestorage,handling,andadministration,whichinformsdecisionsonwhethertodiscardproducts11

ornot.Specificstorageandhandlingprotocolsbased

onthepreciseformulationandresultanttemperature

sensitivityofeachvaccinearetypicallyprovidedby

manufacturers.Anydeviationfromtheserecommendedtemperaturecontrolinstructionsnecessitatesdisposalanddestructiontoensurepatientsafety.

TheWHOestimatesthatthevaccineswastagerateisacombinationofthreetypesofwastage:

?Closedvialwastage(Wc):dueprimarilytoinefficienciesinthesupplychain,includingtemperaturecontrol,

temperaturemonitoring,andstockmanagement

duringstorageandtransportation.Accordingtothe

WHO,amaximumof1%wastageratecanbeattributedtoeachstoragefacility.

?Avoidableopenvialwastage(Wao):usually

attributabletoimmunizationworkers’practices,

however,thislikelyonlyaccountsfor5%ofwastage.

?Unavoidableopenvialwastage(Wuo):akeysourceofvaccinewastage,itincludesdiscardeddoses

fromunuseddosesofmulti-dosevials,takinginto

considerationvialsize,sessionsizeanddiscard

time.Theseestimationcanvarysignificantlyacrossvaccinetypesandhealthcaresystems.Forexample,inItaly,25%oftotaldosesoftheDTPa-HBV-IPV/

Hibvaccinewerediscardedduetotemperature

excursionaccordingtoastudyconductedbySilvestrietal.Thisnumbercouldbesignificantlyhigherfor

lowincomecountrieswheretemperatureexcursionequipmentanddataisnotavailable.

Inadditiontoeconomiclosses,thereisasignificantenvironmentalimpactduetothesubstantialenergyinvestmentinthemanufacturing,packaging,storage,andtransportofwastedvaccines.

Temperatureexcursionswhicharenotidentified,and

resultintheuseofsub-potentvaccines,poseasignificantrisktopublichealthcampaigns.TheHerdImmunity

Threshold(HIT)variesbydiseasetransmissibility.For

highlycontagiousdiseasesincludingmeaslesand

polio,estimatedHITsare95%and80%,respectively12.Theadministrationofsub-potentvaccinescanresult

inmuchreducedimmunityresultinginincreased

frequencyofoutbreaksinunprotectedpopulations.

Althoughwidelyperceivedasachallengefacedby

lower-incomecountries,theseeventshavealsobeen

observedinhigher-incomecountries.Forexample,theSydneyLocalHealthDistrictPublicHealthUnitrecentlyidentifiedanincidentinwhichpatientsofaSydneyclinicwerepotentiallyadministeredsub-potentvaccines—duetostorageoutsidethestipulatedtemperatures

—resultingintheneedtorevaccinateover1,000

patients13.Revaccinationnotonlyposesanunnecessaryrisktoindividualsbutdamagespublicconfidencein

immunisationprogrammes,withvaccinehesitancyidentifiedbytheWorldHealthOrganization(WHO)in2019asoneofthetoptenthreatstoglobalhealth14.

Towardssustainablesolutions

Thehealthcaresectorisestimatedtoaccountfor

approximately4.4%ofGlobalGreenhouseGas(GHG)emissions15,withthecoldchainalonecontributing

55%moreGHGemissions(perdollarofrevenue)

thantheautomotiveindustry16.Withanincreasing

emphasisonreducingGHGemissions—highlighted

bytheNHSUK’scommitmenttobecominganetzeronationalhealthserviceby2040—theimportance

ofreducingsupplieremissionsisconsiderable.The

increasingnumberofbiologicsindevelopmentfurtherexacerbatesthesechallenges.AsperIQVIAdata,over50%ofclinical-stageassetsarebiologicswiththe

majorityrequiringtemperaturecontrol17.Reducing

globalrelianceonthecoldchainisthereforecrucialtomitigatetheenvironmentalimpactofGHGsandensureambitiousnet-zerotargetsaremet.

4|TipoftheIceberg:EconomicandEnvironmentalImpactoftheVaccineColdChain

Figure2:Vaccinecoldchainchallenges—notexhaustive

Complexity

Expansivesupplychain

<

<

>

>

requirescoordinationacrossmultipleintermediarypoints,compoundedbystrict

regulatoryrequirementsforstorage,handing,and

distribution,increasinglogisticalchallenges

Coldchain

challenges

Temperature

Freezingoroverheatingofvaccinesreducespotencyleadingtovaccinesbeing

discardedorineffectiveifused

Economicscosts

Management,maintenance,andinvestmentinthecold

chain,coupledwithvaccinewastage,driveupoverall

expensesacrossthevaccinesupply-chain

ESG

Temperaturecontrol

isenergy-intensive,

contributingtohealthcare’scarbonfootprint,withthepharmaceuticalindustry

aloneresponsibleforanestimated4.4%total

GHGemissions

Source:IQVIAEMEAThoughtLeadership

Throughthesimultaneousadoptionofsustainablepracticesandthe

implementationofinnovative

thermostablevaccinesandnovel

technologies,thepharmaceutical

industrycanplayasignificantroleinachievingglobalemissionreductiontargets,promotingenvironmental

sustainability,andensuringaccesstosafeandeffectivevaccinesforall.

Apromisingsolutiontoaddressingproblems

surroundingthecoldchainistheimplementationofthermostabletechnologiesintomodernandexisting

pharmaceuticals.Ahypotheticalthermostablevaccine—asconsideredinthispaper—wouldnotrequire

anycoldchaintransportationorstorageandwouldbefullystableatastoragetemperatureupto30°C(climatezoneIVbconditions).Thiswouldremove

alllogisticssurroundingcoldchainmanagement

andbringstorageandtransportationrequirementsinlinewiththoseofsmallmoleculedrugssuchasparacetamoltablets.

Thetotaleconomicandenvironmentalimpact

ofthermostablevs.coldchainvaccinesremains

elusive.Here,wepresentadata-drivenapproachtounderstandthetotaleconomicandenvironmental

costsofcoldchainvaccinesinEurope,comparethem

tothermostablevaccinesandidentifythemajorcost

driversusingthreedifferentvaccinetypesasexamples.

|5

Methodology

Wetookastepwiseapproach,asillustratedinFigure3,todevelopthewhitepaper,whichincludedhypothesesgeneration,andanextensiveTargetedLiterature

Review(TLR)tounderstandandcollectexisting

insights,datapointsandanalysesthatwouldhelp

quantifytheextentoftheeconomicandenvironmentalimpactofcoldchainrequirementsofvaccines.

FortheTLR,atotal1,008publicationswereidentifiedbytitlefromtheOVIDdatabasewhichprovidesaccesstoarangeofjournals,e-booksandotherdatabasesandisreferencedbyclinicaltrials,bibliographysearches

andHTAwebsites.Thistotalfigurewasreducedto89publicationsthroughscreeningoftheabstractduringtheinsightconsolidationphase,andfurtherreducedto12throughafullpublicationscanningforrelevance.Theseprovidedthedatapointsrequiredandinformedthesubsequentanalyses.Furthermore,weconductedadditionalsecondaryresearchtosupportthedata

gatheringfortheplannedanalyses.

Ouranalysesfocusedonlyoncertainstagesofthe

vaccinelifecycle.Asdataonvaccinemanufacturing

andadministrationwaseitherunavailableorvaried

significantlydependingonthevaccine,wedecided

tofocussolelyoncoldchainvaccinetransportation,

storage,andwastage(Figure4),aswellasthe

environmentalimpact.Wefocusedontheeconomic

andenvironmentalimpactacrosstransport,storage,andwastage,usingthreerepresentativevaccinetypesascasestudies:

Campaignvaccinesthatareroutinelyadministered,e.g.,influenza

Boostervaccinesforadolescentsor

adultsbasedonnationalimmunisationrecommendations,e.g.,Td-containingboostervaccines

Stockpilevaccineswhichareprocured

andstoredaspartofpandemicorsecuritypreparedness,e.g.,H5N1(birdflu)

1

2

3

Figure3:Stepwiseapproachtounderstandvaccinecoldchaineconomicandenvironmentalimpact

Literature

Existinginsights

Analyses

Additional

Conducted

Conclusion

review

consolidation

planning

research

analyses

Conducted

Identifiedkeyinsights

Plannedanalyses

Identifiedgapsin

Usinginsights

Developedkey

literaturereview

whichwouldeither

toquantifythe

ourinputslibrary

fromexisting

conclusions

against

support/disproveour

economicand

fromsecondary

literature,

pre-specified

hypothesesaround

environmental

research

additional

criteria

theeconomicand

environmentalimpactofcoldchainvaccines

impactofcold

chainvaccines

research

conducted

Source:IQVIAStrategyConsulting;IQVIAEMEAThoughtLeadership

6|TipoftheIceberg:EconomicandEnvironmentalImpactoftheVaccineColdChain

Figure4:Economicandenvironmentalimpactanalysescollectionacrossthevaccinelifecycle

Manufacturing

Storage

Processofproducing

Processofmaintaining

vaccinesatcommercial

vaccinesattherequired

scaleinmanufacturing

temperaturefrom

plants,involvingavariety

manufacturingto

Transportation

Physicallymoving/

distributingvaccinesfrom

pointAtopointB,through

variousmodese.g.,

airplane,trucks.Costs

includedarefuel,wages

amongothers

ofcostse.g.,buildingrent,

Administration

Individualsreceiving

theirvaccineby

healthcareproviders;

administrationusing

cold-chainstorage

specialised

facilities,electricitycost

equipmente.g.,

refrigerators,freezers

costsassociatedwith

thisstagearewages,

wastageandoperational

costsofcold-chain

storageequipment

Wastemanagement

Wastetakesplaceateverystageofthevaccinelifecycle,frommanufacturingtoadministrationduetotemperatureexcursions,expirationdatesandunusedvialsatadministration

Source:IQVIAStrategyConsulting;IQVIAEMEAThoughtLeadership

Transportation

Tocalculatethetotaltransportationcostsperdose

ofcoldchainvaccine,wefirstlylookedatthetotal

transportationcostsforthe2023UKinfluenza

campaign,ascalculatedbyIbrahimetal.18,whichthenallowedustocalculatethetotaltransportationcost

perdosebydividingthetotaltransportationcostsperweekbytheaveragenumberofdosesadministered

perweek.Weassumedthattransportationcostsin

GermanyandSpainarelikelytobesimilartothoseintheUK,thereforethetransportationcostperdose,perweekinUKwasappliedtoGermanyandSpainaswell.Toobtainthetotalnumberofdosesadministeredin

theUK,GermanyandSpainforadultsover65yearsold,weleveragedfiguresreportedbytheOECD19.

Thisnumberislikelyanunderestimationoftotal

influenzadosesadministered,giventhatindividualseligibleforaninfluenzavaccinationcompriseotherhigher-riskgroupsbeyondthe65+yearspopulation.

Subsequently,thetotal,yearly,transportationcostsforinfluenzavaccineswerecalculatedbymultiplyingthenumberofdoseswiththecostsperweek.

Tointerrogatethetransportcostsassociatedwith

boosterandstockpiledvaccines,Td-containingboostervaccinesandtheH5N1vaccinewereselectedas

representativeexamples.Giventhelackofavailabledataonthesecosts,thecostperdoseofinfluenzavaccinewasextrapolatedfromtheIbrahimetal.

figuresandappliedtobothvaccines.

ThetotalyearlydosesadministeredofTd-containingboostervaccinesinUK,GermanyandSpainwere

quantifiedusingpubliclyavailableinformationandIQVIAMIDASdata,whereastheH5N1vaccinedoseswereobtainedfrompubliclyavailableinformationontherecentprocurementagreedbetweentheUKandEuropeangovernmentswithCSLSeqirus.

|7

Storage

Toquantifythetotalstoragecosts,webrokedown

thecostsintotwomaincomponents:fixedcosts

andvariablecosts.Thefixedcostsaccountedforthe

installationofsupplychainassetsincludingstorage

devicesandbuildinginfrastructure,whilevariable

costsweredefinedasthecostsforoperatingthe

equipmentandbuildingwherethevaccinesare

stored.Ibrahimet.alhavecalculatedthetotalstoragecostsforthedurationofthe2023influenzacampaign,brokendownintothesetwocostcomponents18.

Wecalculatedthetotalfixedandvariablecostsfor

storinganinfluenzavaccineinrefrigeratedunitsperweek.Usingthis,alongwiththeaverageinfluenza

dosesadministeredperweekintheUK,wequantifiedthefixedandvariablecostsofinfluenzavaccine

storageperdoseperweek.Thetotalyearlystoragecostacrossthethreevaccinetypesinfocusforthiswhitepaperwascalculatedusingthetotalweeksofstoragerequiredandthetotaldosesadministeredperyearasdescribedabove.

Wastage

TheWHOreportedvaccinewastageof1%per

intermediarypointinthevaccinesupplychainduetotemperatureexcursions.Wemappedoutatypicalvaccinejourney(Figure1),identifyingapproximatelysevenintermediarypointsbeforeadministration,

resultinginaminimumtotalwastageof7%fromtransportationandstorage.Weunderstandthat

thisnumbercanbehigher,asreportedbySilvestrietal.where25%oftotaldosesoftheDTPa-HBV-

IPV/Hibvaccinewerediscardedduetotemperature

excursions20.Therefore,weassumethattheremust

bearangeofvaccinesdiscardedduetotemperatureexcursionsalongthesupplychain.Expirationdates

alsocontributetowastage,varyingbyvaccinetype.Tocalculateannualvaccinewastage,weusedthetotalvolumeofvaccinesadministeredperyear,assuming

16%wastageduetotemperatureexcursions,an

averagebetween7%and25%basedondatafrom

boththeWHOandaSilvestrietal20,21.Wastagefromexpirationdateswasestimatedassumingthat13%

ofnon-campaignvaccinesarediscardeddueto

expiration22.Stockpiledvaccineswithaone-yearshelflife,likeH5N1,areassumedtobe100%discarded

after12months.Thetotaleconomicimpactof

wastagewasquantifiedbymultiplyingthetotaldoseswastedbytheaveragelistpriceforeachvaccinetypeintheUK,Germany,andSpain23.

8|TipoftheIceberg:EconomicandEnvironmentalImpactoftheVaccineColdChain

Environmentalimpactcalculation

WeleveragedPatenaudeetal.’sGreenhouseGas(GHG)emissionsestimatesforAstraZenecasCOVISHIELD?

astheassumptionforallvaccineswhichrequirethesametemperaturecontrolrange,i.e.,between2-8°C.

Thispublicationfocusedonninemarkets,including

theUKandSpain24.ToestimatetheGHGemissions

forGermany,wetooktheaverageoftheUKsGHG

emissionsandSpainsGHGemissions.ThetotalyearlyGHGemissionsfromthethreevaccinesinfocuswere

calculatedbyfirstlyquantifyingtheemissionsperdoseandthenmultiplyingthatfigurebythetotalamountofdosesadministeredperyear.Similarly,theEuropean

GHGemissionswerecalculatedbymultiplyingwiththedoseestimatesdescribedabove.

Furthermore,wecalculatedthefinancialcosts

correspondingtotheenvironmentalimpactofthecoldchainvaccinesinfocusforthiswhitepaperbyapplyingthecarbonpricesaspublishedbytheWorldBankfor2024forUK,Germany,andSpain.ForEurope,weusedanaveragecarbonprice.

Estimatingeconomicandenvironmentalimpactofvaccineadministration

inEurope

AtaEuropeanlevel,toquantifytheeconomicand

environmentalimpact,wefirstlyestimatedthetotalvaccinedosesadministeredinoneyearusingthe

WHOreportedglobaltotalandthenmultipliedthisby29%,asthisrepresentstheproportionadministeredinHigh-IncomeCountries(HIC).WefurtherappliedthetotalEuropeanpopulationasapercentageof

thetotalpopulationofHICtoarriveattheestimateddosesadministeredinEurope(~523milliondosesin2022).Usingthisfigure,wewereabletocalculatethetransportation,storageandwastagecostsassociatedwithcoldchainvaccines,usingthesameinputsas

discussedabove.

Forthecostcomparisonbetweenacoldchain

vaccineandathermostablevaccine,weexamined

twodifferentscenariosforthethermostablevaccine:

thebasecasescenarioandthebestcasescenario,eachwithdifferentassumptionsregardingstorageandwastage.Weassumedthattransportation

costswillremainthesame,giventhatthemodesoftransportationandcostsassociatedwiththemwilllikelybethesame.Ontheotherhand,storageand

wastagecostsarelikelytodiffersubstantiallybetweencoldchainandthermostablevaccinesduetothe

limitedneedfortemperaturecontrolequipmentandrisksoftemperatureexcursionsandexpirationdates.

Results

Inthissectionwewillshowthetotalannualeconomicandenvironmentalimpactofcoldchainvaccines.Weanalysedtheoveralleconomicimpact,compared