By Celia Luterbacher
It’s one of the wealthiest nations in the world, yet Switzerland is struggling to maintain stocks of 16 key vaccines, forcing doctors to adapt their practices. What’s causing the shortfall, and what’s being done about it?
Primarily affected are ‘combination’ vaccines, which protect against multiple diseases – for example diphtheria, tetanus, polio, pertussis (whooping cough), and a form of meningitis – with a single jab.
With restricted access to these critical vaccines from pharmaceutical manufacturers, doctors have been left to tap into their own local clinic or hospital reserves, or to rely on the remaining stocks from wholesalers.
But it’s not just Swiss healthcare providers who are struggling to make ends meet.
“This isn’t a Swiss problem – it’s an international problem. However, I can’t remember a situation like this in my 30 years of professional life as a vaccination expert,” Daniel Desgrandchamps, a paediatrics and infectious disease specialist, told swissinfo.ch.
According to the World Health Organizationexternal link, in 2015, 77% of European countries reported experiencing a shortage of at least one vaccine since the beginning of the year.
Vaccine production is struggling to keep up with an increasing global demand, due in part to large-scale vaccination programmes being deployed in African and Asian countries. Production is also becoming more centralised, with just a few large pharmaceutical companies – like Switzerland’s Novartis and Roche, as well as Pfizer and Sanofi – controlling most of the market.
Then there’s the question of profit. According to a report by Swiss public television, RTS, vaccines – which are administered at only a few key points in a person’s life (birth, injury, international travel, etc.) – may be viewed as less profitable prospects by pharmaceutical companies than drugs that are taken on a more regular basis. Testing and approval processes for new vaccines are also very costly and time-consuming for companies.
Desgrandchamps adds that Switzerland’s small size may also play a role in the domestic shortage.
“We have a very small market for pharmaceutical companies, and so producers might feel reluctant to submit vaccines for testing and approval by the authorities,” he says.
Combinations, alternatives, and delays
In July, the Federal Office for Public Health and the Federal Vaccination Commission issued recommendations for doctors to help them adapt their immunisation practices. The Swiss Society for Infectious Disease has also suggested alternatives to certain vaccines.
With combination vaccines in short supply, an obvious solution might seem to be to give several individual vaccines rather than one multi-purpose shot. But these so-called ‘monovalent’ vaccines are rarely manufactured anymore, having fallen out of favour with the convenience of combination vaccines.
This phenomenon has complicated the shortage problem. For example, Switzerland recommends that patients hospitalised with injuries receive tetanus vaccinations. The standard dose also contains diphtheria protection, which “piggybacks” on the tetanus vaccine to help reinforce immunity in the general population.
So, what are doctors to do when the combined diphtheria-tetanus vaccine runs out?
“You have to switch to a different diphtheria-tetanus combination vaccine with an additional polio or pertussis component. You end up having to give polio or pertussis vaccine to a person who doesn’t necessarily need it. It’s not dangerous, but you don’t like to have that because you just want to give patients the things they need,” Desgrandchamps says.
Doctors must also decide whether a vaccine is indispensable in the first place. For example, polio vaccination is recommended for adults travelling to certain countries. But without adequate supplies, doctors must decide, based on an individual’s risk of contracting the disease, between skipping the vaccine or using a formula designed for children – which can potentially have more severe side effects in adults. In some cases, alternative travel vaccines, which aren’t covered by Switzerland’s basic health insurance plan, may also cost more.
A final option is to delay vaccination in some individuals in favour of patients whose need is more urgent.
“The Federal Office of Public Health recommends vaccinating all young people between the ages of 25 and 29, as well as pregnant women during the second or third trimester, against pertussis. But we’re currently saving the remaining doses for pregnant women, so they can pass the antibodies on to their babies,” explains Laurence Rochat, Assistant Clinical Director of the Vaccination and Travel Medicine Center at the Policlinique Médicale Universitaire in Lausanne.
She adds that in her experience, most patients adapt fairly easily to these changes.
“I would estimate that we have to adapt our vaccine schedule every three or four consultations. Most people cope well with the situation, accept the proposed alternative, and don’t complain much about extra costs,” Rochat says.
The recent implementation of two recommendations from the Swiss cabinet, issued last year as part of a report on national vaccine storage and distribution best practices, show promise for improving the situation in Switzerland.
First, all vaccine shortages likely to last more than 14 days are now published online by the Federal Office for National Economic Supply. Second, manufacturers are required by law to submit enough vaccines to a central stockpile to meet national demand for three to four months.
So far, due to the supply bottleneck, progress in building up the stockpile has been slow – and for some critical vaccines, supplies are still non-existent. But Desgrandchamps is hopeful.
“I am confident that central storage will ameliorate the situation. There are still open questions, but I think it is a major step forward,” he says.
A possible future strategy for Switzerland, he adds, could be following the example of Austria and the UK and establishing centralised vaccine importation. This would involve making a deal with a specific company to provide a certain number of vaccines for a set price. Failure to supply the agreed number of doses would result in a fine for the manufacturer.
“Currently, companies deliver vaccines first to countries where they have an agreement for global supply, to avoid penalties. Countries like Switzerland with an open market usually come last,” Desgrandchamps explains.
No vaccine is compulsory in Switzerland, so it’s up to the patients to decide if they want to get vaccinated. However, the Swiss Vaccination Plan recommends immunisations for various diseases at different stages of life, both for the general population and certain at-risk groups. Recommendations are formulated based on the regularly updated opinions of experts from the Federal Vaccination Commission, Federal Office of Public Health, Swiss Agency for Therapeutic Products, Swissmedic, and the World Health Organization.
The cost of most basic vaccines is reimbursed by Swiss compulsory health insurance. There are some exceptions, such as the HPV (human papillomavirus) vaccine, which may be covered by certain cantonal programmes; and vaccines recommended for international travellers, which are usually covered by a complementary insurance plan