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Review article
Review of vaccine packaging formats and their key features
Revisión de los formatos de presentación de vacunas y sus principales características
Silvia Domínguez-Fernándeza,
Corresponding author
s.dominguez@ieinstituto.es

Corresponding author.
, Jose Antonio Forcada-Segarrab, Inmaculada Cuesta-Esteveb, Silvia Fernández-Fernándeza,c, Rosario Cáceres Fernández-Bolañosd, Guadalupe Fontán-Vinagrea, Roberto Guerrero-Menéndeza
a Instituto Español de Investigación Enfermera, Consejo General de Colegios Oficiales de Enfermería de Spain, Madrid, Spain
b Asociación Nacional de Enfermería y Vacunas (ANENVAC), Valencia, Spain
c Unidad de Atención Primaria, Centro de Salud Rafael Alberti, Madrid, Spain
d Colegio Oficial de Farmacéuticos de Sevilla, Sevilla, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">Within the framework of systematic immunisation schedules&#44; and the administration of recommended immunogens&#44; regardless of their funding&#44; the main objectives of immunisation are to enjoy good health throughout all life stages and not to relinquish autonomy as a person&#46;<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">Vaccination is one of the most effective and safest public health interventions&#46; Immunisation or vaccination is one of the most commonly performed health processes throughout the life of a healthy person&#46; It comes into play before a person&#39;s birth&#44; with the vaccinating of a woman during pregnancy&#44; then later with the infant&#44; continuing during childhood and adolescence&#44; reaching adulthood and continuing throughout old age&#46; Indeed&#44; it is present at all stages of life&#46;<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> It is also used for sick people with risk factors due to underlying diseases&#44; chronic diseases&#44; or in special situations of vulnerability&#46; Immunisation also represents a safe and effective benefit in the prevention of complications&#46;<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">In Spain&#44; nurses play an essential role in the promotion and implementation of immunisation&#44; for which they require adequate training and information for its development&#46;<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">Vaccination timing is one of the key situations for the appearance of errors&#46; Among the most frequent errors are those related to the administration of the wrong vaccine and those associated with an incorrect indication of the vaccine&#46;<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> Nurses must therefore be familiar with the presentation characteristics of vaccines for proper handling&#44; administration&#44; and disposal&#46; As a result&#44; the existence of protocols or strategies aimed at avoiding errors in the handling and administration of immunogens is essential&#46; In keeping with this approach&#44; this study differentiates 2 priority objectives&#58; to explore the implications of the presentation formats of vaccines in use&#44; in terms of sustainability&#44; safety&#44; and the preferences of use reported by nurses and to develop a proposal regarding the essential concepts of the types of vaccine presentations that can serve as a guide for use by nurses&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Material and methods</span><p id="p0025" class="elsevierStylePara elsevierViewall">A narrative review was conducted related to the logistical&#44; ergonomic&#44; and practical aspects of the different presentation formats of vaccines&#46; To this end&#44; a search was carried out in PubMed&#44; CINAHL&#44; and MEDLINE for the relevant literature published in English and Spanish from 2018 to 2023&#46; Of the former&#44; those available in full text&#44; related to the presentation formats&#44; were chosen&#46; In a subsequent phase&#44; those that appeared focused solely on logistical aspects in countries outside the context comparable to Spain and those studies that were focused on combined vaccines were excluded&#46; The search terms were contained in the title&#47;abstract and focused on the vaccine presentation&#46; The search strategy and the process of including articles are contained in <a class="elsevierStyleCrossRef" href="#f0005">Fig&#46; 1</a>&#46; The design of the included studies is highly varied and provides different levels of evidence&#58; randomised clinical trial &#40;1&#41;&#44; observational studies &#40;8&#41;&#44; survey-based studies &#40;6&#41;&#44; and review articles &#40;4&#41;&#46; Most of the primary sources &#40;14&#41; are based on studies carried out in European countries &#40;8&#41;&#44; with only one carried out in Spain&#46; The articles obtained and their brief description are represented in <a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#46; The literature review led to grouping the findings into 4 main aspects&#58; vaccine presentation formats&#59; their sustainability&#59; their safety&#44; and nurses&#39; preferences in clinical practice&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><elsevierMultimedia ident="t0005"></elsevierMultimedia></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Results</span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Vaccine presentation formats</span><p id="p0030" class="elsevierStylePara elsevierViewall">From the perspective of the pharmacotechnics of vaccines for parenteral use&#44; they can be classified based on the number of doses provided by a single presentation&#44; or on the preparation process of the drug before its administration&#46; This classification is represented in <a class="elsevierStyleCrossRef" href="#f0010">Fig&#46; 2</a>&#44; which proposes the fundamental concepts in the presentation of vaccines&#44; which can serve as a guide for nurses in their care practice&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0035" class="elsevierStylePara elsevierViewall">According to RD 175&#47;2001<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a> of February 23&#44; which approves the rules for the correct preparation and quality control of magistral formulas and official preparations&#44; the formulations are protected by packaging material&#44; which may be primary or secondary depending on whether or not it is in contact with the product&#46; The primary packaging is the packaging that is in contact with the product and protects it directly &#40;the vial or the pre-filled syringe&#41;&#46; The secondary packaging is intended to create a loading unit that helps in the reservation and transfer of the product &#40;blister or external box&#41;&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">According to the first classification based on the number of doses&#44; we call a <span class="elsevierStyleItalic">single-dose vaccine</span> that presentation intended to administer a single dose to a patient&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">If&#44; on the other hand&#44; with a single specialty we can administer more than one dose&#44; we will find the following formats&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Multi-dose vials</span>&#58; We will call those vaccines in which the same vial contains several doses&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Multi-single-dose</span> presentation&#58; Those whose secondary packaging contains several individualised doses&#46; There are presentations with a greater or lesser amount of secondary packaging on the market&#46; Each of these doses is presented independently in its primary packaging &#40;vials&#44; pre-filled syringes&#41;&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">And&#44; a combination of the two above is the <span class="elsevierStyleItalic">multi-dose present</span>ation&#44; whose secondary packaging contains several multi-dose vials&#46;</p><p id="p0065" class="elsevierStylePara elsevierViewall">Depending on the process of preparing the vaccine for administration&#44; we can talk about&#58;</p><p id="p0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Formulas that require reconstitution&#58;</span> These are preparations in which&#44; to reach the final drug intended to be administered&#44; they require prior preparation&#44; generally adding a solvent to a solute in solid or liquid form&#46;</p><p id="p0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Completely liquid formulas</span>&#58; They do not require reconstitution&#46; When the primary packaging of these formulas is a pre-filled syringe&#44; we are talking about <span class="elsevierStyleItalic">ready-to-use formulas</span> &#40;RTU&#41;&#46;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0080" class="elsevierStylePara elsevierViewall">Taking these definitions into account&#44; we will find vaccines&#44; approved by the Spanish Medicines Agency&#44; that combine these formats&#46; For example&#44; there are specialties in multi-dose vials that also require reconstitution&#44; an example of this is ComirnatyOmicron XBB&#46;1&#46;5&#44; with National Code &#40;CN&#41; 7&#8239;632&#8239;344 and registration number &#40;NR&#41; 1&#8239;201&#8239;528&#8239;019&#44; fully liquid multi-dose vials such as MenQuadfi &#40;presentation of 10 vials&#41; CN 763017&#44; Jcovden CN 7300038&#44; and NR 1201525001&#59; English&#58; single-dose presentations with 2 vials&#44; one containing the antigen powder and the other containing a suspension for reconstitution&#44; and a syringe to be filled with the reconstituted suspension&#44; such as Shingrix CN 7293040 and NR 1181272001&#46; We also have single-dose vaccines that require reconstitution&#44; in which the solvent is in a pre-filled syringe that draws up the solute from a vial&#44; such as Proquad CN 6542767 and NR 05323010 or Stamaril CN 6542972 and NR 65098&#59; ready-to-use vaccines&#44; such as Boostrix Polio &#40;CN 6504338&#44; NR 6504338&#41; or Hexyon &#40;CN 7314998 and NR 1130829002&#41;&#44; the latter also has a presentation that serves as an example to illustrate a multi-single dose&#44; Hexyon CN 606140 and NR 113829007&#44; whose outer packaging contains 10 pre-filled syringes&#46;</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Advantages and disadvantages in vaccine presentation formats</span><p id="p0085" class="elsevierStylePara elsevierViewall">Vaccines are traditionally packaged and distributed in vials containing single or multi-dose doses&#46; This approach requires the healthcare professional to prepare the vaccine for injection&#44; draw up the precise dose from the vial with a syringe&#44; administer it to the patient&#44; and store the remaining doses until the vial is empty&#46; Potentially&#44; there are differences in local practices&#44; cultural preferences for certain pharmaceutical formulations and also in terms of vaccine delivery logistics in other countries&#44; which may affect the preference for liquid vaccines&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a> In the study by Basu et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a> they determined the choice of single- or multi-dose vial vaccine packaging type as a crucial element of vaccine coverage&#44; as it is associated with the degree of vaccine wastage&#44; cost effectiveness&#44; logistics&#44; cold chain&#44; and potential safety concerns&#46; In addition&#44; a general economic advantage of multi-dose vials is noted&#44; especially in the context of developing countries&#46;</p><p id="p0090" class="elsevierStylePara elsevierViewall">Pre-filled or RTU syringes are a more recent alternative&#44; which continues to gain popularity among vaccine manufacturers and healthcare professionals&#44; due to several advantages they provide in their routine use&#46; RTU syringes contain the exact dose&#44; reduce drug wastage&#44; and are suitable for routine vaccination&#44; such as influenza&#46;<a class="elsevierStyleCrossRef" href="#bb0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0065"><span class="elsevierStyleSup">13</span></a> These presentations have been shown to improve the effectiveness of the vaccination service&#44; both for the health professionals involved&#44; mainly nurses&#44; and for the organisation itself&#46; Some of the advantages they provide are as follows&#58;<a class="elsevierStyleCrossRef" href="#bb0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a> They save time for health professionals during vaccine preparation&#59; reduce administration costs&#59; speed up and simplify administration&#59; reduce dosing errors and product waste&#59; minimise the potential for microbial cross-contamination and transmission of pathogens&#44; which can occur in doses from the same vial&#59; minimise the storage space required and decrease the amount of waste generated&#46; Reducing steps in vaccine preparation decreases the opportunities for immunisation errors and could affect safety&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Sustainability</span><p id="p0095" class="elsevierStylePara elsevierViewall">Regarding sustainability&#44; a possible global aspect is the rate of vaccine wastage&#46; It is one of the critical quality indicators of an immunisation programme and is defined as the proportion of doses from opened or unopened vaccine vials that are not used for vaccination&#46; According to reports from the World Health Organisation&#44; vaccine wastage worldwide exceeds 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bb0075"><span class="elsevierStyleSup">15</span></a> In this study&#44; developed in Iran&#44; they state that the concern about increased waste when opening multi-dose vials could limit access to vaccination services and contribute to low coverage and&#47;or late protection of children by national vaccination programmes&#46;<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a></p><p id="p0100" class="elsevierStylePara elsevierViewall">Decreasing errors in vaccination can eliminate the need to prepare and use a new vaccine&#44; which would result in less waste and indirectly contribute to sustainability&#46;<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a></p><p id="p0105" class="elsevierStylePara elsevierViewall">Regarding the higher acquisition costs of RTU vaccines&#44; it has been reported that the higher costs are offset by lower administrative costs and greater safety&#44; compared to vaccines in single- and multi-dose vials&#46;<a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a></p><p id="p0110" class="elsevierStylePara elsevierViewall">Few studies on safety for the community and the environment exist&#46; Multi-dose vials reduce waste generation with its consequent benefits in terms of environmental impact&#44;<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a> although many of the vaccines are not available in multi-dose format&#46; We consider that having a formulation&#47;presentation that requires less packaging allows its primary size to be smaller and saves space&#44; both in storage in refrigerators and in the required means of transport&#44; in addition to minimising the waste generated&#46; Presentations that are contained in sustainable packaging such as cardboard or with recyclable materials and without materials such as plastic blisters&#44; should be more highly appreciated&#46; Furthermore&#44; another aspect to consider is the number of needles per dose of vaccine supplied&#46; Adopting measures to reduce the supply of extra needles in the presentation of vaccines can avoid the use of raw materials and the generation of plastic waste&#46;<a class="elsevierStyleCrossRef" href="#bb0080"><span class="elsevierStyleSup">16</span></a> In short&#44; the less packaging the vaccine has&#44; both primary and secondary&#44; the greater its contribution to controlling the impact of the environmental footprint&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">Safety</span><p id="p0115" class="elsevierStylePara elsevierViewall">The prevention of accidental occupational exposures in healthcare professionals has been a long-standing demand by the healthcare community&#46; Percutaneous injuries caused by cannulated needles are those associated with a higher risk of acquiring infections by serum-transmitted microorganisms&#46;<a class="elsevierStyleCrossRef" href="#bb0085"><span class="elsevierStyleSup">17</span></a> At a national level&#44; Order ESS&#47;1451&#47;2013<a class="elsevierStyleCrossRef" href="#bb0090"><span class="elsevierStyleSup">18</span></a> for the prevention of injuries caused by sharp and piercing instruments in the healthcare and hospital sector&#44; states that all needles must have a biosecurity mechanism&#46; Some safety measures for nurses are syringes with a luer-lock system&#44; to avoid accidental disconnections and punctures&#44; and vaccines with anatomical dead space&#44; which prevent product loss&#46; RTU pre-filled syringes&#44; which do not require reconstitution&#44; reduce needle handling&#44; and the consequent risk of accidental punctures&#46;</p><p id="p0120" class="elsevierStylePara elsevierViewall">A vaccine that requires less handling will reduce administration risks&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a> Taking this into account&#44; a fully liquid single-dose vaccine will offer fewer opportunities for error by reducing the risk of incorrect dosing&#44; as there is no need to mix or aspirate the contents of the vials and therefore incomplete aspiration or reconstitution failure can be avoided&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a> It is also known that errors during vaccine preparation could be divided into 2 main categories&#58; errors that could lead to health complications and errors that reduce the effectiveness of immunisation&#46; The preparation of the fully liquid vaccine may lead to fewer immunisation errors compared to the non-fully liquid vaccine&#44; as the latter requires many more preparation steps&#46; In addition&#44; during the preparation of the injectable vaccine&#44; if improper manipulations occur&#44; sterility may be compromised&#44; which could contaminate the product&#46; In a South Korean study of 450 nurses&#44;<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a> several types of safety-related errors were identified in vaccine administration&#44; including problems with reconstitution &#40;incomplete aspiration of the reconstitution vial&#44; spillage or leakage during reconstitution&#41;&#44; handling &#40;deformation of the needle when inserted into the vial stopper&#41;&#44; and administration &#40;using the same needle for reconstitution and injection and administration of unreconstituted solvent&#41;&#46; In this study&#44; approximately half of the participants who detected reconstitution errors discarded them and prepared a new vaccine&#44; increasing patient safety&#46;</p><p id="p0125" class="elsevierStylePara elsevierViewall">Some of the risk reduction strategies could include&#58; training of health professionals&#44; placing labels on storage containers&#44; redesigning labelling&#44; and packaging of vaccines&#46;<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">Preferences of nurses in clinical practice</span><p id="p0130" class="elsevierStylePara elsevierViewall">Health professionals value positively any approach&#44; method&#44; or system that prevents errors in the administration of vaccines&#46; The incorporation of safety measures and quality control during the vaccination process also boosts confidence&#44; both in the population and in health professionals&#44; which&#44; in turn&#44; promotes vaccination rates and ensures the success of the immunisation programme&#46; It is important that nurses participate and have a say in the decision-making process&#44; similarly to other professionals involved in vaccination&#46;<a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a></p><p id="p0135" class="elsevierStylePara elsevierViewall">Several studies&#44;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bb0095"><span class="elsevierStyleSup">19&#8211;21</span></a> have demonstrated that nurses have a positive perception regarding the inclusion of vaccines with RTU presentation and even preference for these presentations&#46;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> Some factors could be&#58; the time required for preparation&#59;<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a> the ability to reduce possible erroneous handling and dosage errors&#59; the generation of waste per vaccination&#44; and the scheduling of the time assigned to each vaccination in the vaccination services&#46;<a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a></p><p id="p0140" class="elsevierStylePara elsevierViewall">The characteristics of RTU vaccines offer advantages in the management of vaccination appointments&#44; allowing them to be stored if the vaccination appointment is postponed&#46;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0145" class="elsevierStylePara elsevierViewall">However&#44; vaccines that require reconstitution must be used immediately after vaccination&#44; otherwise they must be discarded&#46;</p></span></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0105">Conclusions and implications for clinical practice</span><p id="p0150" class="elsevierStylePara elsevierViewall">There are few national level studies that address logistic&#44; ergonomic&#44; and practical aspects of the different vaccine presentation formats&#46;</p><p id="p0155" class="elsevierStylePara elsevierViewall">Regarding the type of professionals involved in the act of vaccination&#44; it should be noted that&#44; in the international context&#44; this includes doctors as well as nurses&#44; although there may be differences between Spain and other countries&#46;<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a></p><p id="p0160" class="elsevierStylePara elsevierViewall">In the section &#8220;Presentation formats of vaccines&#8221;&#44; content is provided on the different presentation formats of vaccines and their summary classification &#40;<a class="elsevierStyleCrossRef" href="#f0010">Fig&#46; 2</a>&#41;&#44; as a guide for nurses and other professionals involved in the vaccination process&#46; Of note is that knowledge exists regarding the fully liquid formulation&#44; specifically&#44; with the RTU presentation format or pre-filled siringe&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bb0060"><span class="elsevierStyleSup">12&#8211;14</span></a> There is also information at an international level&#44; analysing the benefits and disadvantages of multi- and single-dose vaccines&#46;<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a></p><p id="p0165" class="elsevierStylePara elsevierViewall">With regard to sustainability&#44; speaking in terms of packaging&#44; storage in refrigerators&#44; and means of transport&#44; among others&#44; we consider that it is a fundamental aspect that should be taken into account for its contribution to reducing environmental impact and that is poorly developed in the existing literature&#46; It is also worth mentioning the reduction in vaccination errors and&#44; therefore&#44; vaccine waste&#44; as a relevant aspect in relation to sustainability&#46;</p><p id="p0170" class="elsevierStylePara elsevierViewall">According to several studies&#44;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0105"><span class="elsevierStyleSup">21</span></a> it is clear that nurses have a positive perception regarding the inclusion of vaccines in RTU presentation&#46; In short&#44; we can conclude that RTU vaccines provide safety for the act of immunisation&#44; save time in handling&#44; flexibility in the time of use and reduce errors&#44; which implies an increase in safety&#46;</p></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0110">Funding</span><p id="p0175" class="elsevierStylePara elsevierViewall">The authors external to the Spanish Institute of Nursing Research declare that they have received funding from the <span class="elsevierStyleGrantSponsor" id="gts0005">General Council of Official Colleges of Nursing of Spain</span> for the preparation of this manuscript&#46;</p></span></span>"
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              "titulo" => "Vaccine presentation formats"
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              "titulo" => "Advantages and disadvantages in vaccine presentation formats"
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              "titulo" => "Sustainability"
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    "fechaRecibido" => "2024-02-08"
    "fechaAceptado" => "2024-06-17"
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            0 => "Vacunas"
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        "resumen" => "<span id="as0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Aims</span><p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">To explore the implications for use of the different vaccine packaging options&#44; in terms of sustainability&#44; safety&#44; and nurses&#39; preferences&#59; as well as to elaborate a proposal for main concepts of vaccine packaging that could serve as a user guide for nurses&#46;</p></span> <span id="as0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Methods</span><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">A literature review has been carried out about logistic&#44; ergonomic&#44; and practical aspects of the different vaccine packaging options&#46; The search was performed in PubMed&#44; CINAHL&#44; and MEDLINE databases&#46; Initially&#44; 99 sources were identified&#44; of which 19 articles were included for review&#46;</p></span> <span id="as0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Review&#47;Results</span><p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">The findings have been grouped in 4 categories&#58; description of vaccine packaging options&#44; and implications in sustainability&#44; safety&#44; and nurses&#39; preferences in clinical practice&#46;</p></span> <span id="as0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Conclusions and implications for practice</span><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Nationwide&#44; there are just a few studies addressing logistic&#44; ergonomic&#44; and practical aspects of the different vaccine packaging options&#46; Regarding the review process of packaging formats&#44; a descriptive section within the document has been developed by experts&#44; including a summary chart&#46; There exists knowledge about liquid formulations&#44; in particular&#44; the prefilled-syringe and multi-dose formats&#46; In relation to sustainability&#44; in terms of packaging&#44; cold storage&#44; and transport&#44; among others&#59; we consider that these are main aspects that should be addressed by its contribution to the reduction of environmental impact&#59; given its scarce presence in the current literature&#46;</p></span>"
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        "resumen" => "<span id="as0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Objetivos</span><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">Explorar las implicaciones de los formatos de presentaci&#243;n de las vacunas en su uso&#44; en t&#233;rminos de sostenibilidad&#44; la seguridad y la percepci&#243;n de las enfermeras&#59; as&#237; como elaborar una propuesta de los conceptos fundamentales de presentaci&#243;n de vacunas que puedan servir de gu&#237;a de uso para enfermeras&#46;</p></span> <span id="as0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Material y m&#233;todos</span><p id="sp0045" class="elsevierStyleSimplePara elsevierViewall">Se llev&#243; a cabo una revisi&#243;n de la literatura en busca de informaci&#243;n sobre aspectos log&#237;sticos&#44; ergon&#243;micos y pr&#225;cticos de los distintos formatos de presentaci&#243;n de las vacunas&#46; La b&#250;squeda se diferentes bases de datos&#46; Se incluyeron 19 art&#237;culos en la revisi&#243;n&#46;</p></span> <span id="as0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Desarrollo&#47;Resultados</span><p id="sp0050" class="elsevierStyleSimplePara elsevierViewall">Se han agrupado los hallazgos en cuatro categor&#237;as&#58; formatos de presentaci&#243;n de las vacunas&#44; sostenibilidad&#44; seguridad y preferencia por las enfermeras en la pr&#225;ctica cl&#237;nica&#46;</p></span> <span id="as0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Conclusiones e implicaciones para la pr&#225;ctica</span><p id="sp0055" class="elsevierStyleSimplePara elsevierViewall">A nivel nacional&#44; existen escasos estudios que versen de los aspectos log&#237;sticos&#44; ergon&#243;micos y pr&#225;cticos de los distintos formatos de presentaci&#243;n de las vacunas&#46; En cuanto a la revisi&#243;n de los distintos formatos de presentaci&#243;n&#44; se ha elaborado un apartado espec&#237;fico en el documento por profesionales expertas en la materia y una figura resumen&#46; Existe conocimiento acerca de la formulaci&#243;n totalmente l&#237;quida&#44; en concreto&#44; con el formato de presentaci&#243;n de jeringa precargada y de las presentaciones multidosis y monodosis&#46; Con respecto a la sostenibilidad&#44; en t&#233;rminos de embalaje&#44; almacenamiento en neveras y medio de transporte&#44; entre otros&#59; consideramos que es un aspecto fundamental que debiera ser tenido en cuenta por su contribuci&#243;n a la reducci&#243;n en el impacto medioambiental&#59; y que se encuentra escasamente desarrollado en la bibliograf&#237;a existente&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="np4005">Please cite this article as&#58; Dom&#237;nguez-Fern&#225;ndez S&#44; Forcada-Segarra JA&#44; Cuesta-Esteve I&#44; Fern&#225;ndez-Fern&#225;ndez S&#44; C&#225;ceres Fern&#225;ndez-Bola&#241;os R&#44; Font&#225;n-Vinagre G&#44; Guerrero-Men&#233;ndez R&#46; Revisi&#243;n de los formatos de presentaci&#243;n de vacunas y sus principales caracter&#237;sticas&#46; Vacunas&#46; 2024&#46; <span class="elsevierStyleInterRef" id="ir3005" href="https://doi.org/10.1016/j.vacune.2024.10.001">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;vacune&#46;2024&#46;10&#46;001</span>&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Conclusions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abdoulaye-Alfa et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mixed method study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multi-dose and vaccine wastage rates&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Basu and Rustagi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Narrative review&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Comparison of multi-dose vaccines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cuesta et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preferences for ready-to-use vaccines by professionals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">De Coster et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Time and motion study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Comparison between liquid vaccines and vaccines requiring reconstitution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Icardi et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mixed method study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Explains the preferences for ready-to-use vaccines versus vaccines requiring reconstitution&#46; It also provides data on preparation times&#44; preferences&#44; risk of errors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ilboudo et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Economic differences between single and multi-dose vaccine doses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kaucley et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abandonment rates&#44; handling of multi-dose vials and unsafe vaccination practices during immunisation sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lee et al&#46;<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cross-sectional study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Error experience with reconstituted vaccines&#44; explains preferences for ready-to-use vaccines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lloyd et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Discrete choice model study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Explains preparation times&#44; probability of handling errors and dosing errors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mai et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Descriptive study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rates of use and loss of doses of vaccines from multi-dose and single-dose vials&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Markarian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">2022</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Narrative review&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blow-fill-seal &#40;BFS&#41; system consisting of pre-filled plastic ampoules that connect to a needle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mart&#237;nez&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">2021</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Narrative review&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Includes some considerations on vial and syringe formats&#44; and the uses of each&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mvundura et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sustainability and vaccine waste rates in developing countries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nkenyi et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retrospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccine waste rates in Cameroon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Rivers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">2022</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Narrative interview&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advances in biopharmaceutical products and parenteral administration of products&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shelle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">2022</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Narrative review&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advantages of pre-filled syringes and the challenges of their use for developing countries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Usuf&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">2018</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prospective study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Difference between 2 types of waste and data on vaccine waste by type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Wallace et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">2018</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mixed method study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Information on missed vaccination opportunities and wasted vaccines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Zahraei et al&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multi-centre descriptive study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sustainability and vaccine waste rates in Iran&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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ISSN: 24451460
Original language: English
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es en pt

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