In some cases, such as in Rwanda, no expansion was deemed necessary. In other countries national-level interviewees reported that there had been an expansion or modernisation of the cold chain in preparation for the introduction, although this was generally at the national and sub-national levels, rather LDN-193189 in vivo than in facilities. There was a discrepancy between some national- and facility-level

responses, with the former reporting cold chain expansion whilst the latter reported none. It is not clear whether this discrepancy was because expected expansions had not occurred, or whether facility staff had not realised that new equipment received (sometimes up to a year earlier) was for a particular vaccine introduction. In four countries, the presentation of other vaccines had changed (pentavalent in Cameroon, Kenya and Mali, and PCV in Rwanda), which reduced their cold chain requirement, making capacity available for the new vaccine. Finally, some districts and a minority of facilities reported using adaptive strategies, such as more frequent vaccine deliveries, in order to manage their cold chain space. “There is a problem with the cold chain because the volume [of vaccines] is bigger and districts

are struggling with the cold chain… there is no space. They find more [the health centres] have to take small quantities; we send them the remainder when there is an opportunity. This creates a risk of stock outs Guatemala was an exception in that no assessment was conducted before the introduction and there was no nationally-organised cold chain expansion. Some equipment was reported to have been procured at sub-national levels after the introduction. Interviewees in most countries reported no effect on regulatory policies, with some exceptions. In Kenya, WHO worked to strengthen the country’s Pharmacy and Poisons Board in order to register the new vaccine. It was felt that this would be beneficial for future vaccines. In Mali, the national regulatory process was bypassed for both Men A and PCV vaccines. In almost doing so, some interviewees argued that this weakened national ownership and

domestic regulatory processes. In most countries the new vaccines were not thought to have affected the functioning of their ICCs. However, in Mali (for Men A) and in Rwanda, membership of the committees was extended to additional stakeholders. In Ethiopia some interviewees felt that the ICC had been strengthened by the introduction, particularly because of highly active thematic sub-committees. Vaccination is, in general, well accepted and this was the case for the new vaccines too, with high acceptance and demand reported. Only a minority of facilities reported that they had experienced any resistance from the community regarding the new vaccine – this was most common in Rwanda for the HPV vaccine, or because of a fear of the effect of receiving two vaccinations at once (e.g. in Ethiopia, where PCV and pentavalent were given at the same time).