Continuous Temperature Tracking: The Lives of Vaccines Albert Koroloff, MPH Oregon Immunization Program National Immunization Conference Washington, DC, March 30, 2011 Hello, my name is Albert and I am here to talk a bit about Oregon's experience with requiring continuous- tracking thermometers of all of our VFC providers. From the far away land of trailblazers, microbrews and the almost militant dedication to recycling. Happy to be here!

“There are two kinds of people, those who finish what they start and so on.” - Robert Byrne In 2005 discuss began among the group about the lack of confidence we had in basic thermometers. 2006 decided to roll out to Public 2007 did the same for private Fortunately, we had access to CDC special project funds which allowed us to purchase continuous tracking Dicksons for all public and many private clinics.

Oregon Provider Agreement Use calibrated and NIST or ASTM certified continuous-tracking thermometers or other OIP-approved devices in both refrigerator and freezer units used to store VFC vaccines. -2011 Oregon VFC Provider Agreement, Section 7 Here is the language we have inserted in our provider agreement. Of course, we had it approved by CDC prior to putting it in. Only difference is the word “Continuous tracking”

Oregon’s Thermometer Guide Oregon has created a thermometer guide for it’s VFC clinics to access. This guide is reviewed and revised on a semi-annual basis. It can be accessed on the Oregon Immunization website and you are welcome to use it. We would appreciate quick email stating your intent to use and a small footnoted acknowledgement would be great.

Not all thermometers are created equal Paper continuous (Provided by Oregon VFC in 2006 and 2007) Basic Min/Max Digital continuous (Many Oregon providers have moved to this unit) Wireless continuous (Several large Oregon health providers have gone wireless) The first question you might ask is, what do you consider continuous tracking? We get this question a lot, especially when we first added the requirement. It can be a little confusing so here is a brief overview: 1)The first and least expensive is the standard vial model. These are extremely basic and are rarely NIST certified. 2) The min/max models come in a range of styles and prices. This is probably the type that most clinics around the country are using. In fact, we have seen these passed out for free by manufacturer reps. 3) The Dickson is the probably the most basic continuous tracking thermometer. This is the one that we had seen most often in our provider clinics (and there is a reason for that in…which I will tell you in a moment). 4) The Lascar digital is a cost effective, non-paper based continuous logger that we discovered through a lot of research. Clinics were have struggles with the Dicksons and we wanted to offer them an option. As it turns out, these units are more accurate, less expensive and more compact. Isn't technology grand. 5) Finally we have the wireless systems. These come in a variety of options and price ranges. Many of our large health systems, Kaiser for example, have moved to this style of tracking. The biggest benefit is the ability to set up alarm options and check temperature status from any location via the internet.

Not all refrigerators are created equal Home-style Lab-grade One welcome side effect that came from our new requirement has been it’s effect on the type of equipment our clinics purchase. Twice a day logs cant capture what continuous can. Looking at these graphs, you can see that upgrading equipment is a much easier sell. In the last two years we have had many, many clinics move over to lab-grade equipment and we credit much of that to continuous tracking (and the bills that came from excursions..based on continuous tracking).

Continuous vs. twice-a-day 44 41 41 41 40 40 39 37 35 Biggest benefit is the transparency that we now have into the “lives” of vaccine…or maybe more accurately…the lives of refrigerators. Often times our clinics will tell us that they don’t believe they had an excursion because their twice a day logs were always perfect. What we have found is that it’s not uncommon (such as in this example) for a refrigerator to have great twice a day temps and have undergone multiple excursions. Twice-a-day checks 8:15AM and 4:30PM oF

"Even a broken clock is right twice a day." - Unknown I think this quote says it best:

It’s not enough just to have continuous logging, clinics must use it. Simply having a continuous logger is not enough. We have seen plenty of examples of clinics with approved equipment who have no idea how to set up the equipment or review the data. When that happens we encounter charts like this one. Recording with no one paying attention. The tell- tale sign is a graph that runs for several months.

Challenges Medical clinic staff: The added expense of new equipment, staff time, training and heightened anxiety/stress over fluctuating temperatures. VFC Program staff: The learning curve in understanding various equipment types and associated software suites. More staff time and resources devoted to reviewing logs, technical support and clinic staff training. Clinic staff are worried about their jobs and providers are worried about their practice and the loss of revenue and clientele. Since continuous tracking captures so much information, it’s inevitable that more excursions will get caught. Recalls are challenging for all involved. They usually require us to drop everything and attend to the issue. The cause stress, raised tempers, angry parents, frustrated providers and, sometimes, less community- level confidence in the clinic and immunizations.

Benefits Reduces loss: Increased “visibility“ of vaccine temperatures translates into more accurate and narrowed excursion windows (i.e. a weekend excursion becomes a one-hour excursion). “Best Practice”: According to NIST, continuous tracking equipment is “critical to the effective storage and monitoring of vaccine.”1 Improved storage and handling : Helps clinic staff make a case for better equipment and visualize the problem; A picture is worth a thousand words. Vaccine viability: Helps assure that vaccines going to Oregon’s children are fully potent and protective. 1. Michal Chojnacky, NIST Physicist. 2010 Vaccine University presentation

Study: Most Children Strongly Opposed to Children’s Healthcare WASHINGTON - A recent survey of children found that they are not in favor of increased doctor visits and vaccinations.

Public Health Educator Oregon Immunization Program Albert Koroloff, MPH Public Health Educator Oregon Immunization Program 971-673-0330 Albert.m.koroloff@state.or.us