Search

Despite massive progress in vaccine coverage globally, the region of sub-Saharan Africa is lagging behind and not on track for Sustainable Development Goal 3 by 2030. Subnational under-immunisation, related to geographical and social heterogeneity, is part of the problem. System-wide changes could transform current immunisation systems to become more sustainable, resilient and inclusive. A framework is proposed that captures the complexity of immunisation systems and offers directions for sustainable redesign. Insights were extracted from literature, stakeholder workshops, and field research in Rwanda and Kenya. A conceptual model of the national immunisation system was co-developed and validated with stakeholders. Leverage points were suggested for intervention scenario building. The Immunisation System Diagram assembles the paradigms of planned and emergency immunisation in one system and emphasizes the synchronized flows of vaccine receiver, vaccinator and vaccine. Six feedback loops capture the main subsystems. Sustainability and resilience are assessed based on loop dominance and dependency on exogenous factors such as donor funding and vaccine stockpiles. In group model building workshops, the diagram invites stakeholders to share their mental models, to assess the system’s performance and to trigger detection of root causes and leverage points. The framework provides a systems-approach for problem structuring and policy design. ispartof: A Systems-Based Framework for Immunisation System Design: Six Loops, Three Flows, Two Paradigms vol:12 issue:1 pages:36-51 status: accepted

Funding Information: This work was funded by VLIR-UOS, grant numbers TZ2019SIN263 and TZ2020JOI032A101. Publisher Copyright: © Concern is justified observing the link between the AIDS and COVID-19 pandemics. COVID-19 outcomes are significantly worse in many people living with HIV (PLHIV), even when vaccinated, because of their impaired immune system. Moreover, CD4 T-cells are affected by both HIV and SARS-CoV-2.1-3 SARS-CoV-2 variants can evolve in immunosuppressed patients due to prolonged viral replication in the context of an inadequate immune response.4 Accelerated intrahost evolution of SARS-CoV-2 was reported in a South African HIV patient with antiretroviral therapy (ART) failure.5 6 With 25 million HIV patients in sub-Saharan Africa (SSA) of whom an estimated 8 million are not virologically suppressed, this potentially creates a reservoir for future variants. Such variants, arising in PLHIV anywhere in the world, can spread to other continents, as has been reported for variants of concern (VoCs) (Beta, Omicron) and variants of interest (B.1.6.20, B.1.640.2) that arose in Africa.7-9 Conversely, the COVID-19 pandemic impacts HIV treatment programmes, due to supply chain issues, overburdening of healthcare systems, limiting access to testing, treatment and prevention programmes and further increasing inequalities.10 Modelled COVID-19 disruptions of HIV programmes in SSA included decreased functionality of HIV prevention programmes, HIV testing and treatment, healthcare services such as viral load testing, adherence counselling, drug regimen switches and ART interruptions, which may lead to selection of drug-resistant HIV.11 A 6-month interruption affecting 50% of the population would lead to a median number of excess deaths of 296 000, during 1 year. Scientists advocate for the AIDS and COVID-19 pandemics in Africa to be addressed simultaneously, by increasing African access to COVID-19 vaccines, prioritising research on the interaction between HIV care and COVID-19, maintaining high-quality HIV services and integrating health services for both viruses.7 Both the COVID-19 and the AIDS pandemic, more specifically the issue of HIV drug resistance (HIVDR), have previously been described as wicked problems which are best studied as complex adaptive systems (CASs).12-15Wicked problems consist of diverse interconnected factors and require complexity-informed and locally adapted solutions rather than one solution that fits all. We recently designed a qualitative model of all known factors influencing HIVDR in SSA and analysed its complexity.13 Our detailed systems map featured three main feedback loops driving HIVDR, representing (1) the alternation between adherence and non-adherence, (2) the impact of an overburdened healthcare system and (3) the importance of sustaining global efforts of tackling HIVDR even when new antiretroviral drugs with high genetic barriers become available. These HIV-related feedback loops are interconnected with COVID-19 pandemic impact (in yellow, figure 1). The loop starts from PLHIV with an unsuppressed viral load, which weakens the immune system and may in turn slow down immune clearance of SARS-CoV-2, allowing prolonged replication and mutation of the virus in the context of an inadequate immune response. Prolonged viral clearance facilitates the selection of immune escape SARS-CoV-2 variants. Variants may emerge that have a selective advantage and therefore may spread through populations due to increased transmissibility (with possibly increased virulence), thereby creating an additional burden on the healthcare system, putting the overall healthcare system and the HIV care at risk. These stressors on the healthcare system lead to a higher risk of unsuppressed viral load in PLHIV, increasing the risk of HIVDR. Figure 1 shows the need to address both wicked problems simultaneously and to do so in a complexity-informed manner as they are inevitably linked and influence each other. Evidently, the exact interconnections between both pandemics need to be locally assessed. For instance, a study in South Africa showed that while lockdown severely impacted HIV testing and ART initiation, ART provision was largely maintained, indicating that the strength of the connection between the virological suppression-related loop and the pandemic, indicated in figure 1, are context-dependent.16 publishersversion published

The distribution of COVID-19 vaccines has proved to be a challenging task for public health authorities in many countries. Among several decisions involved in the task, allocating limited available vaccines to administration points is indeed critical. However, the operation management literature lacks evidence-based mathematical models that could support effective, efficient, sustainable and equitable vaccine allocation decision. This paper develops the fundamentals of a decision support system for COVID-19 vaccine allocation inside countries. The proposed DSS intends to support public health authorities in real-time by illustrating possible vaccine alternatives. The system could also inform and support other actors in the COVID19 distribution for planning and collaboration. Two illustrative cases for the COVID-19 vaccine allocation have been investigated to highlight potential benefits of our methodology.

The research project “COVID-19 Network Technology-based Responsive Action” (CONTRA), funded by the Research Council of Norway, commenced in June 2020. The CONTRA project develops a decision support system (DSS) based on mathematical modeling and stochastic optimization, and machine learning tools for designing a robust COVID-19 vaccine distribution network. The project follows two main objectives within two phases. In response to the on-going COVID-19 outbreak, rapid analyses will provide actionable advice to public health authorities in Norway regarding vaccine distribution and delivery to responders. This phase involved a systematic study of vaccine distribution system actors in Norway and their decision-making needs. Based on such insights, the project will develop a DSS based on mathematical models to support designing the vaccine distribution network. The DSS should contribute to the effectiveness, efficiency, equity, and sustainability of the COVID-19 vaccine distribution. The proposed solution will also support vaccine distribution in future pandemics. The report describes the results of the first work package (WP) in the CONTRA project. The WP1 aims to identify the key actors in the vaccine distribution network in Norway, map their relation to each other, and distinguish critical decisions in the system. Moreover, the report presents an overview of related research on vaccine distribution networks, related decision support systems, and the progress in the literature about the COVID-19 pandemic. Through preliminary interviews, document review, and a workshop with multiple representatives from Norwegian public health authorities, the current vaccine distribution system is analyzed, and its actors have been mapped. This system map is the basis for further discussion both within the project team and with stakeholders. It should be noted that this map will change throughout the project due to the additional insights from other validation opportunities and the fact that the COVID-19 context is dynamic and is changing permanently. However, the system map has served as a basis for the problem definition in the CONTRA project. Based on our findings from the stakeholder workshop and system mapping, we have decided to focus on defining and studying the central vaccine allocation problem (CVAP), which is faced by Public Health Institute (FHI). As such, the CONTRA will investigate the problem of determining the amount of each vaccine to be shipped to every municipality. CVAP is challenged by the scarce amount of vaccines, the current immunization level, population, and priority groups in each municipality. In our project, CVAP will be formulated as a multi-objective resource allocation problem. Specifically, we will define and formulate objectives related to the following performance dimensions: efficacy (e.g., total coverage, coverage per priority group, etc.), efficiency and sustainability (e.g., logistics costs, waste), and fairness (e.g., distribution of efficacy among municipalities). The next step in the project will be to validate the problem definition and develop the mathematical model (second work package). Moreover, two individual reports for the actors map and system map will be published in the upcoming months by project partners.

Previous research has integrated multi-echelon inventory management into the design of a responsive supply chain by the use of the guaranteed service approach. We build further upon this work by integrating the production capacity and product flow to minimize the supply chain's inventories. The production capacity is modeled with a queuing network to handle the variability of the batch production processes as well as the demand variability. We test and validate our model with adapted instances from literature and apply it to the rotavirus vaccine supply chain. This vaccine supply chain is seen as complex on the manufacturing side as well as on the distribution side. For our industrial application we show how this work is embedded in a scenario approach and the contribution of our model to evaluate a single scenario according to multiple performance indicators. For this paper, our scenarios consist of different lead time reduction programmes and varying demand levels. We demonstrate how to extract the best performing scenario. ispartof: FEB Research Report KBI_1621 nrpages: 27 status: published

This paper reviews the relevant literature for designing a vaccine supply chain. We show that vaccines are not like commodities and introduce the typical characteristics of a vaccine supply chain. We study the decisions at strategic, tactical and operational levels that are integrated in the research field on supply chain network design. We provide an overview of how uncertainty is incorporated in the reviewed literature by distinguishing strategic uncertainty and operational variability. Our future vaccine supply chain network needs to be sustainable, hereby taking the preferences of different stakeholders into account for obtaining a set of economical, technological and value key performance indicators that need to be satisfied by the design. This review emphasizes the need of these three types of performance criteria and shows the criteria that are described in the literature. Finally, we identify the most frequently used modeling and solution techniques and discuss the real-life applicability of the research up to now. ispartof: FEB Research Report KBI_1414 nrpages: 73 status: published

Many rigorous models have been developed to support health care system design. However, embedding these models in a broader stakeholder based framework, will substantially enhance the societal and human impact of the health care service delivery. Moreover, the acceptance of the (re)designed health care system will be much more evident for all stakeholders involved. These broader base of stakeholders will deliver a balanced set of Key Performance Indicators, against which the new design options or scenarios will be evaluated. These scenarios will be the outcome of an iterative design and modelling process moderated by a group of key stakeholders. Subsequently, a multi-criteria ranking method will reveal a shortlist of championing scenarios. Finally, a group decision process will decide on the final design choice. We build upon an exemplary model of a Nuclear Magnetic Resonance scanning department. ispartof: FEB Research Report KBI_1323 vol:61 pages:215-225 nrpages: 35 status: published

Research and development portfolio management is traditionally technologically and financially dominated, with little or no attention to the sustainable focus, which represents the triple bottom line: not only financial (and technical) issues but also human and environmental values. This is mainly due to the lack of quantified and reliable data on the human aspects of product/service development: usability, ecology, ethics, product experience, perceived quality etc. Even if these data are available, then consistent decision support tools are not ready available. Based on the findings from an industry review, we developed a DEA model that permits to support strategic R&D portfolio management. We underscore the usability of this approach with real life examples from two different industries: consumables and materials manufacturing (polymers). ispartof: FBE Research Report KBI_1128 nrpages: 35 status: published