Finally, while CTC implementation does not require the use of cold boxes, their use during this study allowed us to protect vaccines from high temperatures

(reported ambient temperatures reached 39 °C) and direct sunlight, and they remain a known ‘signal’ of vaccination activities within the community. Although MenAfriVac is not the only vaccine to be kept outside the 2–8 °C range, it is the first vaccine approved with this type of variation by WHO, and this study marks the first demonstration of potential benefits from this type of use in low income setting. This landmark decision opens the door for the development of Galunisertib new immunization strategies and approaches to ensure the vaccine reaches all those who are at risk, not just those reached by a cold chain. However in order to achieve CTC vaccine labels, close collaboration with manufacturers, regulatory experts and WHO technical staff is essential. The data that is necessary for these types of variations is not yet systematically generated, and collaboration to define the parameters for which additional testing

should follow in order to apply for a variation is essential [13]. As the current CTC work aims to take advantage of existing stability without requiring reformulation, the length of time available in a CTC is likely to be constrained by the limited stability of today’s vaccines. This means CTC will likely provide benefits in the very Sodium butyrate last mile, rather than alleviate cold chain inhibitors capacity issues higher up in the supply chain. However, NSC 683864 further work to assess full impact on health care workers, coverage and potential cost savings from the approach is needed. In the longer term, combining the CTC workstream with other more upstream efforts on vaccine development and thermostability, and generating the data necessary to achieve a CTC license systematically, have the potential to enable routine EPI services without cold chain for longer periods of time and should be explored. The operational costs of the campaign were covered

within the standard new vaccine introduction support window to the Government of Benin by the Global Alliance for Vaccine and Immunization; project Optimize, a WHO/PATH collaboration funded by the Bill & Melinda Gates Foundation, provided additional specific funding for training, supervision and the evaluation. The authors wish to extend their sincere thanks to the following: For operational and planning support, the Ministry of Health in Benin, the WHO country office in Benin, especially Dr. Aristide Sousou and Dr. Jose Biey; AMP Benin, in particular Philippe Jaillard. Regulatory support and expertise from Maria Baca-Estrada, Tong Wu, Dean Smith and their colleagues at Health Canada; and from Carmen Rodriguez and Nora Dellepiane at WHO, Quality Safety and Standards team.