Challenges and Innovations of Vaccine Cold Chain Distribution in Developing Countries: A Narrative Review

Vaccines are among the most effective public health interventions for reducing morbidity and mortality from infectious diseases, yet their effectiveness depends on maintaining vaccine potency throughout the cold chain from manufacture to administration. In many low- and middle-income countries, where disease burden is very high, weaknesses in cold chain systems continue to compromise immunisation programme performance and equitable access. Despite decades of investment, evidence indicates that cold chain failures remain common, yet the factors driving persistent gaps and the real-world impact of emerging innovations are not consistently synthesised. The objective of the review was to assess the major challenges affecting vaccine cold chain distribution in developing countries and to synthesise current evidence on technological and operational innovations aimed at addressing these constraints.
A narrative review methodology was employed, drawing on peer-reviewed literature and relevant grey literature published between 2008 and 2025. Searches were conducted in PubMed, Scopus and Google Scholar. Data were extracted and analysed thematically, focusing on logistical, infrastructural, workforce, geographic, economic, and policy-related dimensions of cold chain performance.
The review revealed persistent challenges, including unreliable electricity supply, inadequate storage and transport capacity, long distribution routes, limited funding for maintenance, fragmented governance and shortages of trained personnel. These factors contribute to temperature excursions, vaccine wastage and stock-outs, particularly in remote and underserved settings. Meanwhile, several innovations have demonstrated potential to strengthen cold chain systems. Solar direct-drive refrigeration, real-time temperature monitoring, electronic logistics management information systems, and drone-enabled last-mile delivery have improved reliability, visibility and access in selected contexts. However, many innovations remain pilot-based, donor dependent and insufficiently integrated into national systems.
These findings highlight that strengthening vaccine cold chain systems in developing countries requires a systems-based approach. Sustainable improvement depends not only on technological innovation but also on coordinated investments in governance, financing, workforce capacity, maintenance and data integration.

Vaccines, Cold-chain

1. Adeyemo, K. S., Mbata, A. O., & Balogun, O. D. (2021). The Role of Cold Chain Logistics in Vaccine Distribution: Addressing Equity and Access Challenges in Sub-Saharan Africa. International Journal of Multidisciplinary Research and Growth Evaluation, 2(1), 893–901. https://doi.org/10.54660/.ijmrge.2021.2.1.893-901 [Google Scholar] [Crossref]

2. Al Qahtani, M., Mohsen Elserafy, M., Kumar Thampi, U., & Veettil, S. T. (2022). 24/7 Cold Chain Management System by Primary Health Care Corporation to support the National COVID-19 Mass Vaccination Program. Journal of Emergency Medicine, Trauma and Acute Care, 2022(1). https://doi.org/10.5339/jemtac.2022.qhc.56 [Google Scholar] [Crossref]

3. Arogundade, L., Akinwumi, T., Molemodile, S., Nwaononiwu, E., Ezika, J., Yau, I., & Wonodi, C. (2019). Lessons from a training needs assessment to strengthen the capacity of routine immunization service providers in Nigeria. BMC Health Services Research, 19(1), 664. https://doi.org/10.1186/s12913-019-4514-2 [Google Scholar] [Crossref]

4. Ashok, A., Brison, M., & LeTallec, Y. (2017). Improving cold chain systems: Challenges and solutions. Vaccine, 35(17), 2217–2223. https://doi.org/10.1016/j.vaccine.2016.08.045 [Google Scholar] [Crossref]

5. Atiga, O., Tanzubil, B. J., Asaana, J., Ayamba, E. C., Seidu, M. T., & Mohammed, I. (2024). Shortening The Last-Mile: Impact of Zipline Medical Drone Delivery on The Operations of Hard-to-Reach Healthcare Facilities in Northern Ghana. AFRICAN JOURNAL OF APPLIED RESEARCH, 10(1), 178–200. https://doi.org/10.26437/ajar.v10i1.677 [Google Scholar] [Crossref]

6. Betancourt-Cravioto, M., & Zhang, P. (2022). The future of immunization financing in Latin America and the Caribbean. Atlantic Council, Adrienne Arsht Latin America Center. ISBN 978-1-61977-259-5.. ISBN: 978-1-61977-259-5 [Google Scholar] [Crossref]

7. Bogale, H. A., Amhare, A. F., & Bogale, A. A. (2019). Assessment of factors affecting vaccine cold chain management practice in public health institutions in east Gojam zone of Amhara region. BMC Public Health, 19(1), 1433. https://doi.org/10.1186/s12889-019-7786-x [Google Scholar] [Crossref]

8. Brison, M., & LeTallec, Y. (2017). Transforming cold chain performance and management in lower-income countries. Vaccine, 35(17), 2107–2109. https://doi.org/10.1016/j.vaccine.2016.11.067 [Google Scholar] [Crossref]

9. Comes, T., Bergtora Sandvik, K., & Van De Walle, B. (2018). Cold chains interrupted: The use of technology and information for decisions that keep humanitarian vaccines cool. Journal of Humanitarian Logistics and Supply Chain Management, 8(1), 49–69. https://doi.org/10.1108/JHLSCM-03-2017-0006 [Google Scholar] [Crossref]

10. Emelike, S. C. (2025). A Review of Challenges and Opportunities in Vaccine Logistics in Low-Resource Settings. Texila International Journal of Public Health, 13(3). https://doi.org/10.21522/TIJPH.2013.13.03.Art006 [Google Scholar] [Crossref]

11. Endriyas, M., Solomon, T., Belayhun, B., & Mekonnen, E. (2018). Poor quality data challenges conclusion and decision making: Timely analysis of measles confirmed and suspected cases line list in Southern Nations Nationalities and People’s Region, Ethiopia. BMC Infectious Diseases, 18(1), 77. https://doi.org/10.1186/s12879-018-2983-2 [Google Scholar] [Crossref]

12. Fahrni, M. L., Ismail, I. A.-N., Refi, D. M., Almeman, A., Yaakob, N. C., Saman, K. M., Mansor, N. F., Noordin, N., & Babar, Z.-U.-D. (2022). Management of COVID-19 vaccines cold chain logistics: A scoping review. Journal of Pharmaceutical Policy and Practice, 15(1), 16. https://doi.org/10.1186/s40545-022-00411-5 [Google Scholar] [Crossref]

13. Federspiel, F., & Ali, M. (2018). The cholera outbreak in Yemen: Lessons learned and way forward. BMC Public Health, 18(1), 1338. https://doi.org/10.1186/s12889-018-6227-6 [Google Scholar] [Crossref]

14. Fritz, J., Herrick, T., & Gilbert, S. S. (2021). Estimation of health impact from digitalizing last-mile Logistics Management Information Systems (LMIS) in Ethiopia, Tanzania, and Mozambique: A Lives Saved Tool (LiST) model analysis. PLOS ONE, 16(10), e0258354. https://doi.org/10.1371/journal.pone.0258354 [Google Scholar] [Crossref]

15. Frost, D., Mahmud, M., Kaiser, M. S., Musoke, D., Henry, P., & Islam, S. (2021). Innovative approaches to strengthening health systems in low- and middle-income countries: Current models, developments, and challenges. Health Policy and Technology, 10(4), 100567. https://doi.org/10.1016/j.hlpt.2021.100567 [Google Scholar] [Crossref]

16. Geneti, L., Shallo, S. A., Yebasa, M. A., & Daba, D. B. (2024). Health workers’ knowledge and practices toward vaccine cold chain management and its associated factors in a resource-limited setting of Sheger, Oromia, Ethiopia: A multicenter cross-sectional study. BMC Pediatrics, 24(1), 786. https://doi.org/10.1186/s12887-024-05284-y [Google Scholar] [Crossref]

17. Gilbert, S. S., Bulula, N., Yohana, E., Thompson, J., Beylerian, E., Werner, L., & Shearer, J. C. (2020). The impact of an integrated electronic immunization registry and logistics management information system (EIR-eLMIS) on vaccine availability in three regions in Tanzania: A pre-post and time-series analysis. Vaccine, 38(3), 562–569. https://doi.org/10.1016/j.vaccine.2019.10.059 [Google Scholar] [Crossref]

18. Gilbert, S. S., Thakare, N., Ramanujapuram, A., & Akkihal, A. (2017). Assessing stability and performance of a digitally enabled supply chain: Retrospective of a pilot in Uttar Pradesh, India. Vaccine, 35(17), 2203–2208. https://doi.org/10.1016/j.vaccine.2016.11.101 [Google Scholar] [Crossref]

19. Goodarzian, F., Navaei, A., Ehsani, B., Ghasemi, P., & Muñuzuri, J. (2023). Designing an integrated responsive-green-cold vaccine supply chain network using Internet-of-Things: Artificial intelligence-based solutions. Annals of Operations Research, 328(1), 531–575. https://doi.org/10.1007/s10479-022-04713-4 [Google Scholar] [Crossref]

20. Guignard, A., Praet, N., Jusot, V., Bakker, M., & Baril, L. (2019). Introducing new vaccines in low- and middle-income countries: Challenges and approaches. Expert Review of Vaccines, 18(2), 119–131. https://doi.org/10.1080/14760584.2019.1574224 [Google Scholar] [Crossref]

21. Hagedorn, B., Cooper, J., Odutolu, O., Ojukwu, O. M., & Loevinsohn, B. (2025). How decentralized facility financing improved supply chains and product availability in primary healthcare centers, a randomized trial in Nigeria. Public and Global Health. https://doi.org/10.1101/2025.07.21.25331940 [Google Scholar] [Crossref]

22. Haidari, L. A., Connor, D. L., Wateska, A. R., Brown, S. T., Mueller, L. E., Norman, B. A., Schmitz, M. M., Paul, P., Rajgopal, J., Welling, J. S., Leonard, J., Chen, S.-I., & Lee, B. Y. (2013). Augmenting Transport versus Increasing Cold Storage to Improve Vaccine Supply Chains. PLoS ONE, 8(5), e64303. https://doi.org/10.1371/journal.pone.0064303 [Google Scholar] [Crossref]

23. Hasanat, R. T., Arifur Rahman, Md., Mansoor, N., Mohammed, N., Rahman, M. S., & Rasheduzzaman, M. (2020). An IoT based Real-time Data-centric Monitoring System for Vaccine Cold Chain. 2020 IEEE East-West Design & Test Symposium (EWDTS), 1–5. https://doi.org/10.1109/EWDTS50664.2020.9225047 [Google Scholar] [Crossref]

24. HEIKE, W. (2017). Framework for the evaluation of cost-effectiveness of drone use for the last-mile delivery of vaccines (master’s thesis, University of Barcelona, ISGlobal). [Google Scholar] [Crossref]

25. Igboanugo, J. C., & Akobundu, U. U. (2020). Evaluating the Resilience of Public Health Supply Chains During COVID-19 in Sub-Saharan Africa. International Journal of Computer Applications Technology and Research, 09(12). [Google Scholar] [Crossref]

26. James, E. R., Church, L. W. P., Hoffman, S. L., Richie, T. L., Robertson, B. D., Hickey, P. W., Schwartz, D. J., Logan, P. T., Asare, T. D., Jones, M. L., Bay, J. L., Roschel, A. K., Pfeiffer, J. L., Acosta, R. W., Schiavi, E., Acosta, A. M., Noble, M., Henkel, T., & Young, C. (2024). Piloting delivery of PfSPZ vaccines for malaria through a cryogenic vaccine cold chain to travel and military medicine clinics. Journal of Travel Medicine, 31(3), taae007. https://doi.org/10.1093/jtm/taae007 [Google Scholar] [Crossref]

27. Jiang, S., Jia, S., & Guo, H. (2024). Internet of Things (IoT)-enabled framework for a sustainable Vaccine cold chain management system. Heliyon, 10(7), e28910. https://doi.org/10.1016/j.heliyon.2024.e28910 [Google Scholar] [Crossref]

28. Kanja, L. W., Karimi, P. N., Maru, S. M., Kayumba, P. C., & Hitimana, R. (2021). Factors that affect vaccines availability in public health facilities in Nairobi city county: A cross-sectional study. Pan African Medical Journal, 38. https://doi.org/10.11604/pamj.2021.38.72.21580 [Google Scholar] [Crossref]

29. Kartoglu, U., & Ames, H. (2022). Ensuring quality and integrity of vaccines throughout the cold chain: The role of temperature monitoring. Expert Review of Vaccines, 21(6), 799–810. https://doi.org/10.1080/14760584.2022.2061462 [Google Scholar] [Crossref]

30. Kartoglu, U., & Milstien, J. (2014). Tools and approaches to ensure quality of vaccines throughout the cold chain. Expert Review of Vaccines, 13(7), 843–854. https://doi.org/10.1586/14760584.2014.923761 [Google Scholar] [Crossref]

31. Kolter, M. (2021). Optimization of Vaccine Supply Chains in Low- and Middle-Income Countries Utilizing Drones. University of Applied Sciences Munich Bachelor of Engineering in Engineering and Management, 2019 [Google Scholar] [Crossref]

32. Kumar, N., & Jha, A. (2017). Temperature excursion management: A novel approach of quality system in pharmaceutical industry. Saudi Pharmaceutical Journal, 25(2), 176–183. https://doi.org/10.1016/j.jsps.2016.07.001 [Google Scholar] [Crossref]

33. Lloyd, J., & Cheyne, J. (2017). The origins of the vaccine cold chain and a glimpse of the future. Vaccine, 35(17), 2115–2120. https://doi.org/10.1016/j.vaccine.2016.11.097 [Google Scholar] [Crossref]

34. Lundbeck, H., Hakansson, B., & Lloyd, J. S. (1978). A cold box for the transport and storage of vaccines. Bulletin of the World Health Organization, 56 (3): 427-432 (1978) [Google Scholar] [Crossref]

35. Makinen, M., Kaddar, M., Molldrem, V., & Wilson, L. (2012). New vaccine adoption in lower-middle-income countries. Health Policy and Planning, 27(suppl 2), ii39–ii49. https://doi.org/10.1093/heapol/czs036 [Google Scholar] [Crossref]

36. Managing Health Supply Chain, M. (2022). Passive Cold Chain Transportation (Logistics Operational Guide (LOG)). World Food Programme. https://www.wfp.org/ [Google Scholar] [Crossref]

37. McCarney, S., Robertson, J., Arnaud, J., Lorenson, K., & Lloyd, J. (2013). Using solar-powered refrigeration for vaccine storage where other sources of reliable electricity are inadequate or costly. Vaccine, 31(51), 6050–6057. https://doi.org/10.1016/j.vaccine.2013.07.076 [Google Scholar] [Crossref]

38. Modlin, J. F., Schaffner, W., Orenstein, W., & Bandyopadhyay, A. S. (2021). Triumphs of Immunization. The Journal of Infectious Diseases, 224(Supplement_4), S307–S308. https://doi.org/10.1093/infdis/jiab123 [Google Scholar] [Crossref]

39. MUNSHI F, DEBNATH S, SENAN A, PETERS T, GREENING P, & WANG X. (2022). Vaccine cold-chain challenges for fast-track mass COVID-19 vaccination in Bangladesh. International Institute of Refrigeration (IIR). https://doi.org/10.18462/IIR.ICCC2022.1115 [Google Scholar] [Crossref]

40. Myers, D. J., Jessupa, S., McCarney, S., Gueye, A., Diesburga, S. P., Little, J., Muller, N., & Lennon, P. (2019, November). Evaluation of Energy Harvest Control Systems Used with Solar Direct Drive Vaccine Refrigerators and Freezers in Senegal [PATH]. www.path.org [Google Scholar] [Crossref]

41. Namuhaywa, M. M. (2013). Cold Chain and Logistics Management for Expanded Program on Immunization in Busia and Namayingo Districts. Open Science Repository Medicine, open-access, e23050464. https://doi.org/10.7392/openaccess.23050465 [Google Scholar] [Crossref]

42. Nestory, B., Anasel, M., Nyandwi, J. B., & Asingizwe, D. (2022). Vaccine management practices among healthcare workers in Morogoro, Tanzania: A cross-sectional study. Journal of Pharmaceutical Policy and Practice, 15(1), 95. https://doi.org/10.1186/s40545-022-00496-y [Google Scholar] [Crossref]

43. Nidhi Shashikumar. (2025). Optimizing supply chain efficiency in healthcare using predictive modeling and data analytics. International Journal of Science and Research Archive, 15(1), 1331–1341. https://doi.org/10.30574/ijsra.2025.15.1.1107 [Google Scholar] [Crossref]

44. Numbi, F. K. M., & Kupa, B. M. (2017). The potential of next-generation supply chains to ease DRC’s “Casse-tête.” Vaccine, 35(17), 2105–2106. https://doi.org/10.1016/j.vaccine.2016.11.096 [Google Scholar] [Crossref]

45. Ospina-Fadul, M. J., Kremer, P., Stevens, S. E., Haruna, F., Okoh-Owusu, M., Sarpong, G. K., Osei-Kwakye, K., Joshua, B., & Sakyi, O. (2025). Cost-Effectiveness of Aerial Logistics for Immunization: A Model-Based Evaluation of Centralized Storage and Drone Delivery of Vaccines in Ghana Using Empirical Data. Value in Health Regional Issues, 46, 101066. https://doi.org/10.1016/j.vhri.2024.101066 [Google Scholar] [Crossref]

46. Pagliusi, S., Dennehy, M., & Homma, A. (2020). Two decades of vaccine innovations for global public good: Report of the Developing Countries’ Vaccine Manufacturers Network 20th meeting, 21–23 october 2019, Rio de Janeiro, Brazil. Vaccine, 38(36), 5851–5860. https://doi.org/10.1016/j.vaccine.2020.05.062 [Google Scholar] [Crossref]

47. Pambudi, N. A., Sarifudin, A., Gandidi, I. M., & Romadhon, R. (2022). Vaccine cold chain management and cold storage technology to address the challenges of vaccination programs. Energy Reports, 8, 955–972. https://doi.org/10.1016/j.egyr.2021.12.039 [Google Scholar] [Crossref]

48. Prosser, W., Spisak, C., Hatch, B., McCord, J., Tien, M., & Roche, G. (2021). Designing supply chains to meet the growing need of vaccines: Evidence from four countries. Journal of Pharmaceutical Policy and Practice, 14(1), 80. https://doi.org/10.1186/s40545-021-00368-x [Google Scholar] [Crossref]

49. Rashid, M. M.-U. (2020). Identifying constraints in vaccine supply chain: A Case study of Finnish Red Cross. [Google Scholar] [Crossref]

50. Robertson, J., Franzel, L., & Maire, D. (2017). Innovations in cold chain equipment for immunization supply chains. Vaccine, 35(17), 2252–2259. https://doi.org/10.1016/j.vaccine.2016.11.094 [Google Scholar] [Crossref]

51. Rusnack, M. (2021). COVID Vaccine Transport, Storage, and Distribution: Cold Chain Management to Ensure Efficacy. INNOVATIONS in Pharmacy, 12(4), 5. https://doi.org/10.24926/iip.v12i4.4225 [Google Scholar] [Crossref]

52. Sáfadi, M. A. P. (2023). The importance of immunization as a public health instrument. Jornal de Pediatria, 99, S1–S3. https://doi.org/10.1016/j.jped.2022.12.003 [Google Scholar] [Crossref]

53. Saidu, Y., Gu, J., Ngenge, B. M., Nchinjoh, S. C., Adidja, A., Nnang, N. E., Muteh, N. J., Zambou, V. M., Mbanga, C. M., Agbor, V. N., Ousmane, D., Njoh, A. A., Flegere, J., Diack, D., Wiwa, O., Montomoli, E., Clemens, S. A. C., & Clemens, R. (2023). The faces behind vaccination: Unpacking the attitudes, knowledge, and practices of staff of Cameroon’s Expanded program on Immunization. Human Resources for Health, 21(1), 88. https://doi.org/10.1186/s12960-023-00869-7 [Google Scholar] [Crossref]

54. Saraswati, L. D., Ginandjar, P., Budiyono, Martini, Udiyono, A., & Kairul. (2018). Vaccines Cold Chain Monitoring: A Cross-Sectional Study at Three District In Indonesia. IOP Conference Series: Earth and Environmental Science, 116, 012082. https://doi.org/10.1088/1755-1315/116/1/012082 [Google Scholar] [Crossref]

55. Shao-jun Jiang, Z. Z., and Wen-yan Song. (2023). A Real-Time Surveillance System for Vaccine Cold Chain Based o n Internet of Things Technology. Journal of Information Processing Systems, 19(3), 394–406. https://doi.org/10.3745/JIPS.04.0279 [Google Scholar] [Crossref]

56. Shen, A. K., Fields, R., & McQuestion, M. (2014). The future of routine immunization in the developing world: Challenges and opportunities. Global Health: Science and Practice, 2(4), 381–394. https://doi.org/10.9745/GHSP-D-14-00137 [Google Scholar] [Crossref]

57. Sinnei, D. K., Karimi, P. N., Maru, S. M., Karengera, S., & Bizimana, T. (2023). Evaluation of vaccine storage and distribution practices in rural healthcare facilities in Kenya. Journal of Pharmaceutical Policy and Practice, 16(1), 25. https://doi.org/10.1186/s40545-023-00535-2 [Google Scholar] [Crossref]

58. TMSA. (2023, August). Cold Chain Challenges in Remote and Rural Areas: Delivering Vital Goods [Http://temperaturemonitorsolutions.co.za/]. [Google Scholar] [Crossref]

59. To, O., My, I., Eo, A., Oo, A., Fo, A., Am, A., & Co, A. (2019). Challenges in the Logistics Management of Vaccine Cold Chain System in Ile-Ife, Osun State, Nigeria. Journal of Community Medicine and Primary Health Care. 31 (2) 1-12 [Google Scholar] [Crossref]

60. Tsega, A. Y., Hausi, H. T., Steinglass, R., & Chirwa, G. Z. (2014). IMMUNISATION TRAINING NEEDS IN MALAWI. East African Medical Journal Vol. 91 No. 9 September 2014 [Google Scholar] [Crossref]

61. Walldorf, J. A., Date, K. A., Sreenivasan, N., Harris, J. B., & Hyde, T. B. (2017). Lessons Learned from Emergency Response Vaccination Efforts for Cholera, Typhoid, Yellow Fever, and Ebola. Emerging Infectious Diseases, 23(13). https://doi.org/10.3201/eid2313.170550 [Google Scholar] [Crossref]

62. WHO, U. (2014). Achieving immunization targets with the comprehensive effective vaccine management (cEVM) framework (Vol. 2). WHO/UNICEF. [Google Scholar] [Crossref]

63. Woldemichael, B., Bekele, D., & Esmael, A. (2018). Cold Chain Status and Knowledge of Vaccine Providers at Primary Health Care of Units Bale Zone, Southeast Ethiopia: Cross-sectional Study. Immunome Research, 14(1). https://doi.org/10.4172/1745-7580.1000152 [Google Scholar] [Crossref]

64. Yadav, P. (2015). Health Product Supply Chains in Developing Countries: Diagnosis of the Root Causes of Underperformance and an Agenda for Reform. Health Systems & Reform, 1(2), 142–154. https://doi.org/10.4161/23288604.2014.968005 [Google Scholar] [Crossref]

65. Yakum, M. N., Ateudjieu, J., Walter, E. A., & Watcho, P. (2015). Vaccine storage and cold chain monitoring in the North West region of Cameroon: A cross-sectional study. BMC Research Notes, 8(1), 145. https://doi.org/10.1186/s13104-015-1109-9 [Google Scholar] [Crossref]

66. Zarekar, M., Al-Shehabi, H., Dörner, R., Weishaar, H., Lennemann, T., El Bcheraoui, C., & Bernasconi, A. (2025). The impact of information and communication technology on immunisation and immunisation programmes in low-income and middle-income countries: A systematic review and meta-analysis. eBioMedicine, 111, 105520. https://doi.org/10.1016/j.ebiom.2024.105520 [Google Scholar] [Crossref]

67. Zipursky, S., Djingarey, M. H., Lodjo, J.-C., Olodo, L., Tiendrebeogo, S., & Ronveaux, O. (2014). Benefits of using vaccines out of the cold chain: Delivering Meningitis A vaccine in a controlled temperature chain during the mass immunization campaign in Benin. Vaccine, 32(13), 1431–1435. https://doi.org/10.1016/j.vaccine.2014.01.038 [Google Scholar] [Crossref]

• Migrant Health in Morocco: Between Law and Reality
• CaknaMinda: An Educator-Centred Mobile App for Early Screening of Mental Health and Schizophrenia Risks
• Health System and Nursing Strategies for Enhancing Male Participation in Family Planning: Evidence from Tema General Hospital, Ghana.
• From Īśvara-Praṇidhāna to Parā-Bhakti: Convergent Paths of Aṣṭāṅga Yoga and Bhakti Yoga
• Evidence-Based Psycho-Oncological Interventions: A Multimodal Approach to Supportive Care