1. An Evaluation of Vaccine Coolers (Vaxicoolers) Utilized in Public Health Emergency Response and Mass Dispensing Operations in Arkansas Nga Vuong, MAT and Ebony Townsend, MSPH Public Health Associates Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention PHAP Spring Session April 7, 2016 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

2. Public Health Significance  Vaccine Coolers (Vaxicoolers) are used during Public Health Emergency Preparedness response operations that can include the following elements:  Medical Countermeasures  Strategic National Stockpile  Point of Dispensing locations  Regular maintenance and testing are important to ensure the coolers are working at optimal capacity for future field deployment during public health emergencies.

3. Public Health Significance (continued) Vaxicool ® / VaxiPac® AcuTemp® AX27L Mobile Temperature Management Unit  Designed to safely transport critical vaccines, drugs, specimens and other bio-medical material to the point of use.  Owner’s manual reported battery life with 2 properly charged, 14 amp- hour gel cell batteries at ambient temperature (25°C) as followed:  -22°C (freezer mode) – 8+ hrs  4°C (refrigerator mode) – 60+ hrs * Photo of Vaxicooler, AcuTemp AX27L Owner’s Manual

4. Background and Rationale  The Arkansas Department of Health (ADH) Trauma, Preparedness, and EMS (TPE) Branch purchased and distributed Vaxicoolers to be used statewide by the branch and local health units to store and transport vaccines during response operations. *Map of Public Health Regions and Associated Counties, www.healthy.Arkansas.gov

5. Background and Rationale (continued)  Operation Lucy  Local health units (LHUs) with surplus of vaccines, others with low quantities Mass redistribution of vaccines statewide with all 75 counties/LHUs o Avoids LHUs stockpiling and over-purchasing o Avoids vaccines expiring and not being used

6. Background and Rationale (cont.)  Operation Lucy  Challenges: Lack of training for personnel for vaccine storage and transportation o Prior training and Just-In-Time training o Vaccine and monetary loss, equipment failure from improper packaging Limited historic data are available on the past/current viability of the Vaxicoolers (i.e. maintenance, testing, inventory logs).  Action Step: This project aimed to evaluate the battery voltage and temperature range of the existing Vaxicoolers in an effort to assess viability for future vaccine storage and transportation.

8. Methods  Sample of 23 Vaxicoolers  39 Vaxicoolers throughout the state (2012)  ~ 59% of the available Vaxicoolers were tested  56 hour testing interval  Hourly for 8-hour intervals, every 24 hours  Temperature  Battery voltage  Refrigerator Mode  Optimal Range 1.7°C – 7.7°C

9. Methods (continued)  Initial Readings  Must work with battery power only > 13.5 volts on A/C power o Following 24-hour A/C charge  Did NOT meet requirements for deployment Inoperable (no power, leaking batteries, etc.) Vaxicooler A/C power < 13.5 volts  9 Vaxicoolers (39.1%) excluded from further testing

10.  Battery Voltage  Green Zone / Optimal Range Battery is typically at > 10% of its charge capacity > 11.8 volts  Yellow Zone Battery has < 10% 11.5 – 11.8 volts  Red Zone No longer viable for deployment < 11.5 Methods (cont.)

11. Results  Eligible for Deployment  60.9% (n=14) of Vaxicoolers eligible for deployment  ALL maintained optimal temperature readings  Maintaining Optimal Voltage Ranges  14 deployment eligible Vaxicoolers 12 maintained optimal temperature and voltage ranges 2 did not maintain optimal voltage ranges for the duration of the study  ALL deployment eligible Vaxicoolers maintained optimal ranges for at least 24 hours  52.2% (n=12) of the sample maintained both optimal temperature and voltage ranges throughout the study

12. Results (continued)

13. Results (cont.) *Leaking battery acid, broken wiring, no power, etc. ⁺Initial A/C Power reading was below eligible range for deployment requirements

14. Limitations  Hourly check points  No overnight checks  Temperature/Voltage Fluctuations  No automatic way to record any drops in between hourly checks

15. Implications  Reported findings from the Vaxicooler integrity trials to ADH TPE Branch leadership and team members:  Almost half of the sample of Vaxicoolers are working below optimal operating levels for field deployment  As of December 2015, ADH TPE Branch has requested use of PHEP grant funds to purchase 35 Vaxicoolers over the next 5 years, starting with 10 in the first year.  AcuTemp AX27L Unit  AcuTemp AX56L Unit – Data logging capabilities

16. Plan of Action  Conduct further studies to assess other factors that could affect Vaxicooler integrity  Exposure to extreme temperatures  Vaccine packaging configurations and quantity  Frequency of opening/closing  Deployment parameters Deployment length Freezer vs refrigeration mode

17. Plan of Action (continued)  Develop a quality assurance (QA) plan  Conduct quarterly to biannual testing (temperature range / battery life)  Designate a TPE team member(s) to conduct QA testing  Develop and provide training materials for new Vaxicoolers for personnel  Develop and maintain logs:  Inventory (up-to-date point of contacts, locations, last maintenance date, etc.)  QA testing logs (temperature range/battery life)

19. For more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support 4770 Buford Highway NE, Mailstop E-70, Atlanta, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: OSTLTSfeedback@cdc.govWeb: http://www.cdc.gov/stltpublichealthOSTLTSfeedback@cdc.govhttp://www.cdc.gov/stltpublichealth The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Contact me at: Nga Vuong | ypg2@cdc.gov | (501) 352-4615ypg2@cdc.gov Ebony Townsend | wnk5@cdc.gov | (501) 661-2916wnk5@cdc.gov Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support