HighlightsInterviews (158) conducted with immunization personnel in 6 countries.Respondents are interested in vaccines with improved heat and freeze stability.Most involved in vaccine purchases would pay a slight premium for those features.Most saw value in controlled temperature chain (CTC) use of vaccines.Many highlighted the need for careful consideration of CTC risks/benefits.

The widespread use of multidose vaccine containers in low and middle income countries' immunization programs is assumed to have multiple benefits and efficiencies for health systems, yet the broader impacts on immunization coverage, costs, and safety are not well understood. To document what is known on this topic, how it has been studied, and confirm the gaps in evidence that allow us to assess the complex system interactions, the authors undertook a review of published literature that explored the relationship between doses per container and immunization systems. The relationships examined in this study are organized within a systems framework consisting of operational costs, timely coverage, safety, product costs/wastage, and policy/correct use, with the idea that a change in dose per container affects all of them, and the optimal solution will depend on what is prioritized and used to measure performance. Studies on this topic are limited and largely rely on modeling to assess the relationship between doses per container and other aspects of immunization systems. Very few studies attempt to look at how a change in doses per container affects vaccination coverage rates and other systems components simultaneously. This article summarizes the published knowledge on this topic to date and suggests areas of current and future research to ultimately improve decision making around vaccine doses per container and increase understanding of how this decision relates to other program goals.

Highlights8 factors predict the viability of vaccine manufacturers in developing countries.These factors have evolved as the vaccine landscape has changed over 2 decades.A new analysis updates a framework first published in 1997 to assess viability.The updated framework is useful for assessing investments in vaccine manufacturers.