Demand planning for vaccinations using the example of seasonal influenza vaccination - country comparison and implications for Germany

Abstract

Background

Annual vaccination is the most important measure to prevent influenza infection. However, demand planning of influenza vaccines is challenging due to seasonal adaptations of virus strains and long production times. The aim was to analyze how other countries manage the demand planning of seasonal influenza vaccines and to draw implications for the German demand planning system for seasonal (influenza) vaccines.

Methods

A two-stage approach has been adopted. As a first step, an analysis of the German demand planning system was carried out to identify key challenges. Second, an analysis of comparable countries with regard to solution strategies was conducted. For this, six comparator countries were selected based on different healthcare systems and structures (Australia, Canada, Great Britain, Singapore, Switzerland, USA). Targeted searches in PubMed, Google Scholar and on websites of agencies and organizations were performed. Further information was requested through e-mail correspondence with the ministries of health and other relevant institutions. In addition, experts from the pharmaceutical industry in the selected countries were approached via written survey.

Results

Identified challenges in the demand planning of influenza vaccines in Germany include a lack of reliability of the current demand planning system, bureaucratic burden, lack of binding orders, financial liability of GPs, vaccine discard and limited possibilities of reordering. Various approaches have been identified in six comparator countries. Some of them are already implemented in the German system, others could address the challenges in the German demand planning for influenza vaccines. These include vaccine forecast methods, monitoring systems/vaccination registers, a central platform for orders, (earlier) preorders, centralized purchase system, reimbursement of a surplus and reallocation and return systems. The different approaches are discussed and linked to address the challenges of the German system.

Conclusions

Several approaches have been identified that may be suitable to address the challenges of the German system of (influenza) vaccine demand planning. In the future, further investigation is necessary to assess the potential feasibility and implementation on a health policy level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-22420-0.

Background

Seasonal influenza is a highly infectious respiratory disease occurring worldwide. In Germany, influenza results in approximately 17 million symptomatic cases [1]. People aged 60 years and over, pregnant women, people with chronic illnesses, and people with weakened immune systems are particularly at risk of complications and even death [2]. Annual influenza vaccination is the most important preventive measure. The Standing Committee on Vaccination (STIKO) recommends different influenza vaccines for different target groups. For example, people aged 60 years and older are advised to receive an annual vaccination with a quadrivalent high-dose influenza vaccine [1].

The World Health Organization (WHO) and the European Union are aiming for a vaccination coverage of 75% for at-risk populations, which include older adults (≥ 65 years), people with chronic conditions, pregnant women, children aged six months to two years, and healthcare workers [3, 4]. This recommendation has been included in the National Vaccination Plan [5]. In Germany, the influenza vaccination rate among people aged 60 years and over was 47% in the 2020/21 season and 43% in the 2021/22 season [6]. Although 80% of the people aged 60 and over suffer from a chronic illness and can therefore be considered at double risk, only 43% of these people were vaccinated in the 2018/19 season according to an analysis of claims data from the German statutory health insurance (SHI) Barmer covering nine influenza seasons [7]. For medical personnel, a group with a high risk of infection, the influenza vaccination rate was 55% in season 2019/2020 and 58% in season 2022/2023 [8]. Thus, despite a temporary increase due to the COVID-19 pandemic, vaccination rates among risk groups still remain far below the recommended 75% [9].

Influenza vaccines need to be adapted to the circulating virus variants each season [10, 11]. Furthermore, the current production period takes several months, which requires proactive planning [12] and limits the possibility of short-term reorders during the influenza season [13]. In general, demand planning as a component of supply chain management aims to balance demand and supply based on historical data and forecasts. In the specific area of vaccines, demand leads supply, with supply influenced by several factors, including uncertainty in demand, uncertainty in the start and severity of the flu season, and rationally justified under-ordering by vaccinators. The very long lead time for production and the fact that there are several stakeholders with different interests involved also complicate the situation [14]. While there are many reasons for low vaccination rates, including vaccine hesitancy, suboptimal availability can also be a factor. For example, in November 2018, there was a shortage of influenza vaccine in some German federal states. As a result, many practices were unable to offer vaccinations. In addition to the strong flu epidemic in the previous season and delayed ordering by doctors and pharmacists, the demand planning process in Germany was also mentioned as a possible reason [15, 16]. Since 2022, pharmacies in Germany have been authorized to vaccinate individuals aged 18 years and over against influenza, which has added to the complexity of demand planning [17]. In the field of economics, aiming for efficiency in demand and supply means that the economy gets the maximum gains from its scarce resources. For these reasons, knowing how many doses should be produced and when is essential to improving the match between supply and demand [18].

Stuurman et al. distinguish between four general types of procurement planning: (a) national public tenders (e.g., in Scotland), (b) regional public tenders, (c) direct purchase of vaccines by general practitioners (GPs) from manufacturers (e.g., in England and Wales), and (d) direct purchase of vaccines by pharmacies from manufacturers or wholesalers (e.g., in Germany) [19]. These approaches in turn are followed by different approaches and practices of vaccine demand planning.

Aim of this article is to provide insights on influenza vaccine demand planning and its challenges in Germany and to explore practices of influenza vaccine demand planning in other countries that could potentially be applied to address the challenges in the German system. An improved demand planning for seasonal (influenza) vaccines contributes to the overarching aim of increasing (influenza) vaccination coverage without causing excessive discard. The results of this research could also be used to plan the future demand for COVID-19 vaccines. Similar to the influenza vaccination, the STIKO recommends annual vaccination of high-risk groups with a seasonal vaccine adapted to the current virus strain, as suggested by the WHO [13].

Methods.

As shown in Fig. 1, the methodology is divided into two parts: first, the German demand planning system was analyzed with the aim of identifying challenges, and second, demand planning activities in other countries were analyzed. Based on the results, optimization potentials are discussed.

Fig. 1.

Methodological approach

The German demand planning system for seasonal influenza vaccination within the SHI, which covers 90% of the German population, was analyzed [20]. The analyses included related processes, operational levels and stakeholders involved, and timelines. These criteria were considered important by the authors because the description of the processes was at the center of interest, the analysis of the operational levels and the links between the actors was considered necessary to understand the processes, and finally the time aspect was considered crucial in the time-critical demand planning process. Information on the demand planning system was obtained by searching for legal bases, policy documents, guidelines, publications, and on websites of responsible legal institutions, organizations, relevant stakeholders, and interest groups. Further searches were carried out in PubMed and Google Scholar. The targeted search strategy included keywords such as ‘influenza vaccination’, ‘demand planning’, and the respective synonyms. Potentially relevant documents were reviewed in full text. All screening steps were carried out by two researchers. In the event of disagreement, a third person was consulted. Extracted results were subsequently quality checked by a second person. Besides information about the processes of the demand planning system, recommendations for action to improve the vaccine demand planning were taken into account.

In the second step, six comparator countries were selected, namely Australia, Canada, Great Britain, Singapore, Switzerland, and the United States. These countries were chosen as convenient samples because there were also contacts with experts in these countries. However, care has been taken in the selection process to ensure that countries with different health systems and structures are included to provide variation. For example, while Great Britain and Canada can be classified into the Beveridge model, in which healthcare is provided and financed by the government through taxation, ensuring universal coverage for all citizens. In contrast, Switzerland, for example, has a Bismarck healthcare system which is based on social health insurance, financed through mandatory contributions from employers and employees, while many of the other countries employ hybrid models. Australia, Canada, and the United States have decentral systems, while Singapore and Switzerland have centralized healthcare. The characteristics of the selected countries can be found in Additional file 1. For these six countries, information was available in German or English language. Additionally, they have different systems for planning and procuring influenza vaccines, making them suitable for multilevel comparisons. The literature searches regarding the comparator countries followed the same procedure as described above. Results were extracted into pre-developed tables comprising of country, year, category of concept, description of concept, and possible transferability options to the German system. Based on the results, a questionnaire was developed and distributed to pharmaceutical industry experts who were purposively sampled across the six comparison countries (Additional file 2). In order to obtain valid statements, the questionnaire was sent to experts in the position of Market Access Director, who were responsible for launching vaccines in the respective health care system and had at least 20 years of job experience. The questionnaires included open-ended questions on which the literature provided limited or no information. Furthermore, questions were included to verify the identified results in the comparator countries based on the literature. The responses of the questionnaires were analyzed regarding their content on general information about vaccine demand planning and procurement processes, involved stakeholders, timelines, ordering processes, return agreements and pros and cons regarding the current techniques. Subsequently, the information were synthesized with the findings from the literature searches.

Results

The targeted literature searches for the German system and the comparator countries were conducted in PubMed in September 2023 and yielded a total of 1,845 results. Additional information was obtained by searching on websites of responsible legal institutions, organizations, relevant stakeholders, interest groups and Google Scholar. A total of 49 sources were included, as shown in Fig. 2.1

Fig. 2.

Selection of literature

The survey period was six weeks starting from August 28th, 2023. Surveys were returned for Australia, Canada, Singapore, and Switzerland. The characteristics of respondents are shown in Table 1.

Table 1.

Characteristics of survey respondents

Country	Role	Responsibility	Gender	In-country experience
Canada	Market Access Director	In charge for launching vaccines	Male	Over 20 years
Singapore	Market Access Director	In charge for launching vaccines	Female	Over 20 years
Australia	Market Access Director	In charge for launching vaccines	Male	Over 20 years
Switzerland	Market Access Director	In charge for launching vaccines	Male	Over 20 years

Demand planning of influenza vaccines in Germany and identified challenges

The processes of influenza vaccine demand planning in Germany and the stakeholders involved are shown in Fig. 3 and explained in detail below.

Fig. 3.

Processes and stakeholders in the context of influenza vaccine demand planning in Germany

Based on the recommendations of the STIKO, the Vaccination Guideline is published by the Federal Joint Committee (G-BA) in accordance with § 20i paragraph 1 of the German Social Security Code (SGB), Fifth Book (V). It regulates the requirements, and type and scope of vaccinations for people with SHI. According to § 132e paragraph 2 SGB V, the National Association of Statutory Health Insurance Physicians (KBV) reports the demand for influenza vaccines to the Paul-Ehrlich-Institut (PEI) by January 15th each year. The 17 Associations of Statutory Health Insurance Physicians (KVs) receive the estimated demand from their members via online portals. Similarly, the national organization representing the interests of the pharmacists reports the planned order quantities for seasonal influenza vaccines by pharmacies by January 15th each year. The reliability of the demand planning system thus depends on the accuracy of the information about the estimated demand from physicians and pharmacists, which in the past led to challenges. According to the KV Saxony for example, less than 20% of regularly vaccinating medical practices provided information to the demand survey according to § 132e paragraph 2 SGB V in the 2020/2021 season. Some of the data were not plausible, so no serious extrapolation could be made [21]. Another challenge is the large amount of bureaucracy involved in demand planning. For example, the KBV has stated that the current survey of planned order quantities according to § 132e SGB V leads to additional bureaucracy for physicians, KVs, and the KBV [17].

On the side of the manufacturers, information about the number of ordered vaccine doses and the number of doses planned to be supplied to Germany is reported to the PEI.

By March 15th, the PEI, in consultation with the Robert Koch-Institute (RKI), compares the reported demand to the supply planning by the manufacturers. Afterwards, the manufacturers are informed whether their supply targets match the demand provided by the physicians and the pharmacists. This includes an additional reserve of 10%, by comparing the data with the incoming orders for influenza vaccine from manufacturers in accordance with § 29 (1d) of the German Medicinal Products Act (AMG) [§ 132e (2) SGB V]. Furthermore, the PEI is calling on physicians and pharmacists to order vaccines around March if the received orders to that date fall short of the previously determined demand [22]. As physicians are not bound to the order quantities when responding to the demand survey according to § 132e SGB, deviations between expected and actual order quantities have occurred. As a result, physicians have ordered fewer doses of vaccine in the past than the demand estimated by the PEI [23, 24]. Another problem that has been identified is financial liability. According to § 106b paragraph 1a SGB V, doctor’s offices risk recourse claims if their ordered quantity of vaccines deviates from the actual vaccinations administered in an uneconomical manner. For the 2021/2022 and 2022/2023 vaccination seasons, an excess of up to 30% was still deemed economical [§ 106b SGB 1a]. Although the actual risk of recourse in practice may be low, the KBV considers the fear of recourse claims from physicians as a possible reason for cautious ordering practices [17]. On the other hand, unexpectedly low demand, in particular, has led to discards in the past [25].

Each February, the WHO announces the exact strain composition for the northern hemisphere. Based on this, the European Medicines Agency (EMA) issues EU recommendations for the composition of seasonal influenza vaccines every year [26]. In Germany, the PEI is responsible for regulatory procedures concerning vaccines, while the EMA manages the regulatory procedures at the European level. The EMA evaluates pharmacovigilance after licensure of the different influenza vaccines, both with and without strain adaptation [27]. Furthermore, the EMA assesses information on effectiveness provided by marketing authorization holders, public health agencies, ECDC or dedicated consortia such as (until 2022) the consortium of the Development of Robust and Innovative Vaccine Effectiveness (DRIVE) project [28, 29]. After the initial approval of an influenza vaccine, a seasonal approval from either the PEI (for nationally approved vaccines) or the European Commission (for centrally approved vaccines in the EU) is required to review the strain adaptations recommended by the EMA. This yearly adaptation does not require a full marketing authorization procedure, but involves a legally required batch test by the European Official Medicines Control Laboratories (OMCL), such as the PEI [30]. Once the orders have been placed, manufacturing is planned, and manufacturers start producing the vaccines by the end of March at latest. After batch release of the produced adapted seasonal vaccines by the PEI, vaccines are distributed to wholesalers and, in some cases, directly to pharmacies starting in late August. This allows vaccinations to be performed in October and November, as recommended by the RKI [13]. Due to their long production times, reorders of seasonal influenza vaccines are limited, especially for traditional vaccine technologies [13]. This makes accurate and timely demand planning crucial to meet the demand and prevent shortage to prevent shortages.

Figure 4 provides an overview of the described challenges in the German influenza vaccine demand planning process.

Fig. 4.

Challenges of influenza vaccine demand planning in Germany

Demand planning practices of influenza vaccines in other countries

Several approaches to influenza vaccine demand planning and procurement systems have been identified in the comparator countries. Most of the information comes from the literature search and information from the questionnaire survey is labelled accordingly.

Australia

The Australian Technical Advisory Group on Immunisation (ATAGI) publishes specific advice relating to influenza vaccination every year before the influenza season [31]. For the National Immunisation Program, which is a joint initiative from Australian State and Territory Governments to provide free influenza vaccines to people at risk [32], the Department of Health has implemented a Coordinated Vaccine Procurement Arrangement with the States and Territories to secure a supply of essential vaccines [33]. The Commonwealth of Australia receives state-based forecasts for a 3-year period, which are then incorporated into a tendering arrangement. Tender winners are allocated a certain market share based on the value provided. For the distribution of (influenza) vaccines, nationally consistent logistical distribution mechanisms and the use of several airports in order to reduce dependence on only one main destination port are recommended [34]. Immunization providers need to place online orders for influenza vaccines. Providers should order only enough vaccines for a 4-week period to ensure that enough quantities of vaccine are available to all providers. Restrictions on vaccine doses may apply based on supply and demand [35]. Since 2021, reporting influenza vaccinations to the Australian Immunization Register (AIR) is mandatory [36]. Frome these data, influenza related estimates can be drawn for the Australian population [37].

Canada

In Canada, the National Advisory Committee on Immunization (NACI) provides recommendations for the use of vaccines and groups at risk for vaccine-preventable diseases to the Public Health Agency of Canada (PHAC) which publishes vaccine recommendations in the Canadian Immunization Guide [38]. Every year, federal, provincial, and territorial jurisdictions estimate their influenza vaccine needs based on past data, seasonal forecasts, and immunization program requirements.

Via tenders, the Government of Canada, through Public Services and Procurement Canada, has long-term contracts with manufacturers, allowing provincial and territorial governments to purchase vaccines, which are then distributed through public health clinics, doctors’ offices, and, in some areas, local pharmacies [39]. Within the federal/provincial/territorial (F/P/T) bulk purchasing program, through which the vast majority of influenza vaccines are purchased, Public Works and Government Services Canada (PWGSC) manages vaccine tenders and contracts on behalf of all jurisdictions, acting as an agent for the Vaccine Supply Working Group (VSWG). Based on information on surpluses or shortages on influenza vaccine doses, reallocations as well as returns to the suppliers are coordinated [40]. In the past, the tender process often employed a “winner-takes-all” approach, where the lowest-price bidder secured all sales for a given vaccine. Recently, there is a growing shift towards dual-supplier contracts to promote security of the vaccine supply, in which up to two suppliers provide the required vaccine doses. Requires fully interchangeable competitor vaccines [41].

Monitoring of the spread of influenza and influenza-like illnesses is carried out by the national surveillance system FluWatch in which Information on influenza activity are published weekly (during active influenza season) [42]. As balancing vaccine supply and demand is seen as a complex challenge due to uncertainties in both supply-side constraints and demand-side drivers, which complicate adequate production, a proposal to strengthen the vaccine supply by the use of more accurate forecasting methods to predict vaccine demand has been made [41]. This consists of the use and comparison of two common methods of vaccine forecasting. The first is based on the target population which involves calculations about the eligible cohort, dosing, coverage rates, and vaccine wastage, with potential adjustments for specific immunization program needs. The second focusses on previous consumption and estimates future vaccine needs based on historical usage and annual trends [41].

Singapore

Little information has been identified regarding the demand planning of influenza vaccines in Singapore. The Ministry of Health (MOH) reviews vaccination policies and inclusion of vaccines into the National Adult Immunisation Schedule (NAIS) and the National Childhood Immunisation Schedule (NCIS) in consultation with the Expert Committee on Immunisation (ECI) [43]. Influenza activities are routinely monitored based on reports of weekly polyclinic attendances for influenza-like illnesses and clinical specimens positive for influenza viruses [44]. For a consistent supply of influenza vaccines, a tender system exists with the criteria time to market and price. Volumes are usually split between different suppliers for the public sector [survey]. For the private sector, reallocation of vaccine doses may be possible [survey].

Switzerland

In Switzerland, the Swiss Immunization Schedule is created by the Federal Commission for Vaccination Issues (EKIF) in collaboration with the Federal Office of Public Health (BAG). Information on influenza activity is monitored through an information portal by the Federal Office of Public Health [45]. Furthermore, the Federal Office of Public Health informs about all vaccine supply shortages that are expected to last longer than 14 days with details about the expected duration and recommendations for action. In addition, specialists and manufacturers are informed about the availability of vaccines via newsletters and monthly bulletins [46].

In the event of vaccine shortage, the army pharmacy could be used, for example, as national importer and vaccines could be purchased centrally by the Confederation [47]. Additionally, authorized medical personnel can apply for a special license to import vaccines authorized abroad. For this, no additional national authorization procedure for already EU-authorized vaccines is needed [48]. In the event of shortages, manufacturers can apply for a temporary distribution of vaccines in a foreign presentation when (a) the foreign vaccine is identical to the national authorized vaccine and (b) no other vaccine is available for the same application. These applications are usually processed within a few days. A summary and/or patient information leaflet and a customer information letter are sent out with each pack [48]. Generally, influenza vaccine supply shortages are bridged by switching to alternative vaccines or vaccination regimens [48]. To avoid shortages, importers and/or producers can be obliged to keep certain goods permanently in stock in a certain quantity, such as influenza vaccines. The compulsory stockholding system is based on cooperation between the private sector and the state. The companies are obliged by the state to store and rotate the goods so that certain goods are always available. In shortage situations, such as supply bottlenecks, the federal government can release the compulsory stocks by issuing an ordinance on compulsory stock release [48].

Regarding the purchase of influenza vaccines in Switzerland, GPs and pharmacies themselves order their stocks of influenza vaccines directly from the suppliers/manufacturers [48]. Pre-orders of influenza vaccines are being placed by health care professionals through web shops of wholesalers. Usually, there is one binding pre-order. Furthermore, GPs can indicate their expected delivery date. On pre-orders, there is a defined percentage rate of returns per season for which the company will be liable [survey].

Great Britain

In Great Britain, the Joint Committee on Vaccination and Immunization makes recommendations regarding influenza vaccination and eligible groups that are published in the National Flu Immunisation Programme by the UK Health Security Agency [49]. Moreover, the UK Health Security Agency monitors influenza vaccine activity through laboratory and microbiological surveillance, primary and secondary care surveillance, internet-based surveillance, mortality surveillance and international vigilance [50].

Through a central platform for orders through an ImmForm online account, data on vaccine uptake is collected and vaccines can be ordered by health care providers for the National Immunisation Programmes. Wholesale Dealers can order vaccines via the platform with their professional regulatory body registration number [51].

Scotland purchases the influenza vaccines through a dual tender system for the service and product. The vaccine (product) is tendered every year while a tender for a storage and distribution provider (service) occurs every few years. The tenders contain a split agreement award with either a small number of manufacturers or all manufacturers, according to the tendering process and results [e-mail of the Department of Health Scotland (24.07.2023)]. While Scotland has already done so, Wales will also be using centralised procurement for influenza vaccines through tendering from the 2025/26 season [52]. In addition to that, England aims to adopting a centralized purchase system of adult flu vaccine procurement and supply. This would mean that influenza vaccines would be centrally purchased and supplied free-of-charge to pharmacies and practices for use in the national flu vaccination program [53].

USA

In the USA, the Advisory Committee on Immunization Practices (ACIP) gives vaccination recommendations which are published by the Centers for Disease Control and Prevention (CDC) [54]. Multiple monitoring systems that are used year-round to access influenza activities are run by the CDC, e.g., weekly publication of an influenza surveillance report. The surveillance systems contain several components, each focusing on different tasks. For example, besides measuring existing influenza activity, another component of the surveillance system aims on forecasting [55].

The influenza vaccine production and distribution are primarily managed by the private sector, without the CDC involved [56]. Manufacturers and distributors are encouraged to use a distribution strategy in which providers receive smaller shipments to allow as many providers as possible to begin vaccination activities early and in a comparable timeframe in the vaccination season [57].

Through the Influenza Vaccine Availability Tracking System (IVATS), health care providers can get information about the purchase of influenza vaccines from approved, enrolled, and participating wholesale vaccine distributors or manufacturers licensed for influenza vaccine [58].

By pre-booking influenza vaccine doses, providers can ensure that they have the appropriate number and selection of vaccines which not only enables a reliable inventory for providers but also reliable quantities to be produced by manufacturers which thus helps to prevent shortages. Furthermore, it allows practices and clinics to receive their vaccine at a favorable time and gives clinicians the opportunity to proactively notify their patients to book vaccination appointments. Additionally, pre-booking can help ensure more favorable pricing, flexible payment options, and purchasing terms [59].

As influenza vaccine demand and supply is considered challenging due to varying demand and long production times, the Massachusetts Institute of Technology (MIT) Global SCALE Network recommends a “Buyback with Prerequisites” and information hub. The information hub is understood as a central platform for health care providers, distributors and manufactures to keep track of vaccine orders. A type of buyback of excess vaccine inventory from health care providers would be offered which aims to reallocate vaccine doses in terms of a secondary market [14].

Discussion

This mixed-methods study based on a document and literature review complemented by an expert survey aimed to provide insights on influenza vaccine demand planning and its challenges in Germany and explore practices of influenza vaccine demand planning in other countries that could potentially be applied to address the challenges in the German system. Challenges in the demand planning of influenza vaccines in Germany include a lack of reliability of the current demand planning system, bureaucratic burden, lack of binding orders, financial liability of GPs, vaccine discard and limited possibilities of reordering. Various approaches have been identified in six comparator countries. Some of them already exist in the German system, others could address the challenges in the demand planning for influenza vaccines in Germany. In the following discussion, possible applications to the German system are discussed and linked to its challenges.

The demand planning system according to § 132e SGB V

One approach to a more precise demand planning that has not yet been implemented in Germany is the establishment of a central ordering platform. The implementation of a central platform for orders for influenza vaccines with digital tracking of order quantities could enhance reliable demand planning and facilitate estimations of whether the order quantities align with regional demand [60]. To guarantee a comprehensive and dependable data foundation, it may be advantageous to regard the information outlined in § 132e SGB V as mandatory preorders rather than planned order quantities. Preorders are used in the USA, for example, to prevent delays in the supply chain and enable proactive planning and patient contact with vaccinators [61].

With the aim of improving the reliability of demand planning, the existing demand planning system could be adapted by introducing vaccine forecast methods that take into account a greater number of parameters (such as dosage of influenza vaccines, vaccination rates, consumption and discard but also plans/campaigns for increased vaccination rates) [62]. For instance, BIOTECanada, a Canadian vaccine industry association, suggests comparing the two common demand planning methods: (i) estimates based on the target population (assumptions about the target/subpopulation, dosing, vaccination rate, and discard) and (ii) estimates based on past consumptions and average annual increases. It is recommended to carefully examine discrepancies of more than 5% [41].

Expanding the existing monitoring system for influenza could improve demand forecasting precision. In the United States, for example, the monitoring system comprises multiple components, each with a distinct focus. One module focuses on future forecasts, in addition to monitoring influenza activity [63].

As an additional suggestion, conducting representative surveys on the willingness to be vaccinated early in the season could aid in more accurately determining demand [64] and reallocating vaccine doses appropriately. However, as the production process is already completed at the beginning of the season, this would not contribute to increasing vaccination rates.

Bureaucratic burden

To reduce the bureaucratic burden of the current demand planning system, the aforementioned central platform for orders, oriented on the example of Great Britain, could be established and provide a more user-friendly and standardized ordering process [60]. Vaccine manufacturers could enter their estimated order volume on the platform, which could later serve as a template for actual orders and indicate how many of the estimated doses have already been ordered.

Additionally, incorporating data from an influenza vaccination register into demand planning could improve the current information situation, which relies on household surveys and claims data of the SHI. In Australia, reporting on vaccinations to the Australian Immunization Register has been mandatory since 2021 [61]. A report commissioned by the Australian Department of Health recommends using this data to improve influenza vaccine demand planning [34]. The register could also potentially incorporate SHI claims data to provide more accurate information on demand and previous vaccine consumption which could eliminate the need for demand surveys according to § 132e SGB V. Further, it could be organized in a way that allows the general public to indicate their willingness to be vaccinated.

Additionally, an automated system that outputs the respective number of potential vaccination patients in doctors’ offices based on patient files [14] would assist physicians in monitoring vaccinations and provide more precise data on the required order quantities, thus reducing bureaucratic burden. However, an implementation of this would only be possible with an appropriate data protection basis.

Lack of binding to the demand planning system

Preorders instead of surveys could increase commitment and decrease the difference between planned and actual orders. Earlier order placements in terms of preorders, as in November 2023 for the 2024/2025 season at KV Berlin [65], would allow vaccine manufacturers to align their production accordingly and ensure the availability of a sufficient number of vaccines at pharmacies and doctors’ offices while they can also help to reduce delivery times and ensure availability on time.

Reallocation and return systems have been established in Canada and in the private sector in Singapore [40]. The “Bulk Purchase Program” in Canada reports and redistributes vaccine doses to where they are needed considering surpluses and shortages [63]. In case of a surplus or expired vaccine doses, they will be returned to the supplier via the program in return for a credit note, for which a maximum quantity has been contractually agreed in advance [63]. However, to ensure quality requirements regarding the cold chain storing of the vaccines, there may be concerns if the vaccines have already left the pharmacies. Thus, only vaccines that have not left the pharmacies would be eligible for reallocation.

Reimbursement of a surplus, as it was possible for pharmacies in the 2020/2021 season for the centrally purchased influenza vaccines by the Federal Ministry of Health in Germany [66], could help to ensure that physicians do not ultimately order too few vaccine doses out of concern about ordering too many. Optionally, this could be linked to a vaccination target, e.g., a 5% increase.

Financial liability of Doctor’s offices

Reimbursement of a surplus may also help reducing the fear of recourse claims when at the end of the season, physicians still have a surplus of vaccine doses left.

Instead of a recourse, reallocation and return systems, such as those that exist in Canada as part of the “Bulk Purchase Program” [64], could enable efficient distribution in the event of a surplus of vaccine doses to reduce the fear of recourse claims which pay lead to cautious ordering behavior according to the KBV [17]. This way, vaccinators can plan for the required number of vaccine doses without the fear of any repercussions or discard, which thus contributes to increased influenza vaccination rates.

A centralized purchase system, as exemplified by Great Britain [67], can also aid in coordination and enable effective vaccine distribution to mitigate the risk of recourses.

Vaccine discard or shortages

As it is challenging to maintain an adequate supply of vaccine doses to increase influenza vaccination coverage without causing additional discard, the use of preorders as described above may provide more accurate data on demand, leading to more precise order quantities and reduced vaccine discard [survey].

Reallocation and return systems, such as the Canadian model [40], could be implemented to enable efficient redistribution of surplus vaccines and reduce discard. For instance, unused vaccines in pharmacies could be returned to centralized warehouses and redistributed to other locations to ensure optimal use. In the 2018/2019 season, the Bavarian Association of Pharmacists set up an exchange platform for influenza vaccines during a shortage for a fair distribution of remaining influenza vaccines [68].

If there are still excess influenza vaccines in pharmacies after reallocations, it would be possible to conduct additional local, low-hurdle vaccination campaigns during the season to reduce discard and increase influenza vaccination rates. Vaccination campaigns regarding COVID-19 may serve as an example.

Limited possibility of reordering

Earlier and binding preorders would enable a more accurate estimation of the expected demand and associated order quantities as reorders of seasonal influenza vaccines, especially for traditional vaccine technologies, are limited due to their long production times [13].

Reallocation and return systems also offer potential solutions to this challenge [40]. In the event of shortages, such as those caused by higher demand than initially anticipated, vaccinators could receive vaccine doses that were ordered in excess elsewhere via the national redistribution network. This would enable the avoidance of last-minute reorders from vaccine manufacturers and potential discard.

Innovative vaccine technologies, such as mRNA vaccines, contribute to shorter vaccine production times in the future [69]. The COVID-19 pandemic has demonstrated that mRNA vaccines have a significantly reduced production time compared to conventional vaccines and allows for a higher degree of standardization. This makes them particularly attractive for the production of seasonal (influenza) vaccines [69], which could solve the issue of limited reordering options in the future.

Figure 5 presents the proposed strategies linked to these challenges, with the aim of improving the demand planning and procurement of seasonal (influenza) vaccines and consequently, increasing influenza vaccination rates. An overview of the challenges and identified approaches liked to the country of origin can be found in Additional file 3.

Fig. 5.

Proposed strategies to address the challenges in demand planning for influenza vaccines in Germany

The described approaches are assigned to the challenges in the German system. However, changes in one field have an impact on a whole range of processes. For example, preorders can result in more accurately planned orders, improving the reliability of order quantities and reducing discard. Furthermore, other countries have different framework conditions that may challenge the transferability of the identified practices to the German healthcare system. For instance, the procurement of influenza vaccines in Switzerland is subject to the free market economy, whereas in Singapore demand planning and procurement is much more regulated.

The article presents potential strategies to improve demand planning of influenza vaccines in Germany. Some of the solutions presented, such as low-threshold vaccination campaigns, have the potential to not only positively impact demand planning but to also directly contribute to an increase in influenza vaccination rates. This does not extend to all discussed measures; however, adequate demand planning builds the basis for an increase in vaccination rates. Thus, the suggestions presented here might help to improve demand planning and ultimately lead to higher influenza vaccination rates without causing a vaccine shortage or significant surplus. Although the link between improved demand planning and increased vaccination rates is not clear, a good assessment of demand can provide planning certainty and minimize wastage, which is a desirable goal in itself given the scarcity of healthcare resources.

The objective of this article was to raise awareness of the challenges associated with demand planning for seasonal (influenza) vaccines. Furthermore, we aimed to provide possible solutions as a base for future discussions among experts and health policy stakeholders. In addition to discussing possible improvement mechanisms of the German demand planning system, future work that needs to be done is to examine possible solutions for the transfer to the German healthcare system by health policy stakeholders. This will subsequently promote measures to address the challenge of demand planning for seasonal vaccines, such as influenza vaccination.

Limitations

The presented solutions are not exhaustive. Instead, the aim was to generally explore practices in other countries for initiating changes to processes and structures to improve demand planning for seasonal vaccines. Furthermore, it is important to note that structures and processes within countries may evolve over time, e.g., due to new administrations as recently observed in the United States. These shifts could lead to the implementation of alternative or supplementary vaccine demand planning techniques by the time of the articles’ publication. However, this does not impact the relevance of our article, which provides suggestions and recommendations for improving influenza vaccine demand planning. The identification of the challenges in the German demand planning system is based on literature and may thus not include challenges from a practical view of relevant stakeholders. Another limitation is that our article is largely based on secondary sources, which might limit its validity. Nevertheless, we believe that the content provided represents a good starting point for the future discussion of improvements. To extend the results, the identified challenges could be discussed in focus groups and/or in interviews with relevant stakeholders of the German demand planning system and their everyday practice. Furthermore, the designation of responsibilities regarding the check for suitability and transferability from a German health policy perspective was out of scope but would help driving forward the process of structural changes to improve the demand planning of seasonal (influenza) vaccines.

Due to the German-specific focus, we refrained from mapping the different challenges and approaches to demand planning from both, the comparator countries and Germany, and then target the analysis on how they address challenges. Although this would have provided more advantageous information on solution approaches for other countries, this procedure was chosen to provide target-oriented solution approaches for the German system.

Conclusions and implications for practice

Several methods for the demand planning of influenza vaccines have been identified in other countries, some of which may be applicable to address the current challenges of the German system. The following implications can be drawn for practice for a higher reliability to demand forecast and planning of seasonal influenza vaccines in Germany:

• Adapting the current demand planning system, e.g., by using more extensive forecasting methods.

• Reducing bureaucratic burden, e.g., by implementing a central platform for orders.

• Increasing commitment to the demand planning system, e.g., through binding preorders.

• Reducing the financial liability of doctors’ offices, e.g., by the reimbursement of a surplus.

• Improving the distribution of vaccines to reduce vaccine discard or shortages, e.g., by reallocating vaccines in case of a surplus/shortage.

• Dealing with limited possibility of reordering, e.g., through more accurate demand planning and initiating reallocations, while innovative vaccine technologies with shorter production times are evolving.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

ACIP

Advisory Committee on Immunization Practices (Australia)

AIR

Australian Immunization Register

AMG

German Medicinal Products Act

ATAGI

Australian Technical Advisory Group on Immunisation

BAG

Federal Office of Public Health (Switzerland)

CDC

Centers for Disease Control and Prevention (USA)

DRIVE

Development of Robust and Innovative Vaccine Effectiveness

ECI

Expert Committee on Immunisation (Singapore)

EKIF

Federal Commission for Vaccination Issues (Switzerland)

EMA

European Medicines Agency

EU

European Union

F/P/T

Federal/provincial/territorial

G-BA

Federal Joint Committee

GPs

General practitioners

IVATS

Influenza Vaccine Availability Tracking System

KBV

National Association of Statutory Health Insurance Physicians

KVs

Associations of Statutory Health Insurance Physicians

MIT

Massachusetts Institute of Technology

MOH

Ministry of Health (Singapore)

NACI

National Advisory Committee on Immunization (Canada)

NAIS

National Adult Immunisation Schedule (Singapore)

NCIS

National Childhood Immunisation Schedule (Singapore)

OMCL

European Official Medicines Control Laboratories

PEI

Paul-Ehrlich-Institut

PHAC

Public Health Agency of Canada

PWGSC

Public Works and Government Services Canada

RKI

Robert Koch-Institute

SGB

German Social Security Code

SHI

Statutory health insurance

STIKO

The Standing Committee on Vaccination

UK

United Kingdom

USA

United States of America

VSWG

Vaccine Supply Working Group (Canada)

WHO

World Health Organization

Author contributions

AB, CS, PS, and JW made substantial contributions to the conception and design of the work. AB, CS, and PS conducted the literature searches, developed the questionnaire, interpreted the data, and drafted the work. JW, IBD, and BU have substantively revised the draft. All authors read and approved the final manuscript.

Funding

The project was funded by Moderna Germany GmbH.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The research was conducted in compliance with the Helsinki Declaration. No ethics approval was required for this study, as participation was voluntarily, participants of the survey were informed about the purpose of the study and provided their consent to participate by completing the questionnaire and no personal or health-related data was obtained. Additionally, no individuals could be identified from the data, as all responses were anonymized and aggregated.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflict of interest. BU is an employee of Moderna Germany GmbH. IBD did not receive monetary or other compensation for her input and coauthorship.