1. Cold Chain Logistics and Issues: March 25, 2014 IPV Global Workshop

2. The Cold Chain

3. Which are most sensitive to heat?

4. Vaccines damaged by freezing Diphtheria toxoid Hepatitis A Hepatitis B Inactivated Poliovirus Influenza Liquid Hib Liquid Japanese Encephalitis Meningococcal Pertussis Pneumococcal Tetanus Toxoid Typhoid All combination vaccines

5. WHO Recommended Storage Conditions for Vaccines

6. Cold Chain Equipment & Logistics Refrigerators/Freezers – Generators/ Voltage Stabilizers Cold Boxes Vaccine Carriers (Foam Pad) Ice Packs Check condition every time you visit a facility!

7. Refrigerators/Freezers Freezers (-15 to -25 degrees C) – Ice Pack Freezers (24 hours) Refrigerators (usually w/freezer) – Electric Ice Lined Refrigerators – Kerosene – LP Gas – Solar

8. Ice Lined Refrigerators (ILRs) Can maintain temperature for 16 hours without power if operate w/power continuously for at least 8 hours a day!

9. Refrigerators/Freezers Reminders At least 10 cm from wall Off the floor Kept clean, esp. dust in coils Out of direct sunlight Only vaccine to be stored. Opened minimal times per day Generator or kerosene = good ventilation Voltage stabilizers to avoid damage to compressors caused by changes in electricity.

10. Storage of Vaccines in Refrigerators

11. Loading top loading refrigerators

12. New challenges: More storage space is required <2000 =28cm3 Basic EPI6 vaccines 2009 +41 cm3 =110 cm3 Pneumococcal (1 st generation) 2011 +156 cm3 =266 cm3 Rotavirus (1st generation) HPV +45 cm3 >2012** IPV +16 cm3 =311 cm3 =327 cm3 2004 +41 cm3 Pentavalent =69 cm3 Volume of vaccine per fully immunized child* x11 increase in vaccine volume per FIC since 2000 The accelerated introduction of new vaccines speak volumes Volumes affect storage, transport and paperwork Source: WHO/UNICEF * Volume also needed for Measles second dose, Tetanus, Yellow-Fever, Meningitis A, JE and vaccines provided during campaigns. ** Illustrative. Based on 1 dose vial vaccine presentations and first generation of vaccines 12

13. Effective Vaccine Management

14. The to EVM are the nine criteria Stock management

15. Cold Boxes Insulated for short– term use: 2-7 days Used in campaigns or when refrigerator out of order Consideration for use and storage capacity, outside temperature, available transport

16. Vaccine Carriers and Ice Packs

17. Good or Not Good?

18. Effect of melted ice packs in vaccine carriers on labels

19. Multi dose vials Vials where one or more doses of vaccine are used Multi dose vial policy ( open vial policy) – OPV, DTP, TT, DT, Hepatitis B and liquid Hib – Used in subsequent vaccination sessions as long as the expiration date has not passed, the cold chain has been maintained and the VVM has not reached the discard point

20. Tools for monitoring temperature

22. Temperature monitoring chart for facilities

23. Is it working?

24. Vaccine Vial Monitor (VVM)

25. Types of VVMs Available path June 2000

26. Cold Chain in Campaign Setting

27. Cold Chain in Campaign Setting IPV Damaged by freezing temperatures Cool packs or ‘conditioned ice packs’ for vaccine carrier Reliance on VVM for monitoring vaccine potency Vaccine administration requires training

28. Cold Chain Challenges - SIAs Reaching hard to reach populations Distance and Accessibility Seasons Weight and volume of equipment Capacity needs often more than routine storage capacity limited Costs Health worker practices Vaccine management and administration

29. Resources http://www.unicef.org/immunization/index 42071.htmlwww.unicef.org/immunization/index 42071.html http//www.path.org/projects/project- optimize.php http://who.int/vaccines-documents/http://who.int/vaccines-documents/DoxGen/H5- CC.htm www.technet21.org