Post0228 SLOW CHAIN & FAST CHAIN & VVMs 17 February 2000
CONTENTS
1. COMMENTS RE:POST0217 FAST CHAIN
2. THOUGHTS: VVMS TO MANAGE THE COLD CHAIN AND IMPROVE VACCINE DISTRIBUTION
Moderators' note: The moderator is back from the field and home from the
hill.
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1. COMMENTS RE:POST0217 FAST CHAIN
Post0217 FAST CHAIN + CC DOCUMENTS, Hans Everts, WHO/V&B, responded to the
Technet'99 Sub-Group on the Fast Chain draft recommendations. Hans has also
posted the revised document.
The DRAFT document: "Making use of VVMs: Flexible Vaccine Management for
NIDS, SNIDs, and Mop-ups is available for download.
Got to the website:
ftp://ftp.acithn.uq.edu.au/Technet/1-ClickHereForTECHNETfiles/Coldchain/
and click on the file: Fastchain-Jan2000.PDF
or get the file by by email to: [
[email protected]]
[email protected][/email]
with the message: get technet Fastchain-Jan2000.PDF
* While it is too late for changes in this edition of the guidelines,
discussion may continue.
Gary Presthus, WHO/MSU/SDE, a former long time EPI Technical officer, give
an "old timers'" view of what fast chain used to mean when we discussed it
in the late 1980s and early 1990s.
The fast Chain guidelines are specific to campaign mode operations.
* Perhaps we should be talking about a rapid supply chain, with commodities
including vaccines moving through the chain rapidly. Studies in numerous
countries have indicated that many items including drugs, anti-malarials,
and yes vaccines, frequently reach the dispensing facility at or near their
expiry date, despite entering the national supply chain with years of life
remaining.
* Assuming that a slow supply chain equates with poor management and poor
storage conditions for long periods of time, the viability and usefulness
of such items at the end of a very slow supply chain are problematical.
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___________________________________________________________________________
From: [
[email protected]]
[email protected][/email]
Date: Mon, 17 Jan 2000 09:47:19 +0100
To:
Subject: Re:Post0217 FAST CHAIN + CC DOCUMENTS
Dear Allan,
Let me add my 2 cents worth on the Fast Chain.
I started using this term in training courses over ten years ago. Nobody
seemed to like it then as machines were thought to be able to solve all our
problems. (Cold Chain) However as loss of vaccine potency always has two
components time and Temperature I think it is long overdue that time have
its rightful place in the discussion.
I agree with whoever said "The Fast Chain" should not be tied to VVM's.
Time is simply that, the amount of time vaccine is exposed to the wrong
temperature either high or low. The better vaccine programmes are managed
i.e. first in first out longest storage at the highest level the less we
need fridges everywhere.
I would be happy to review any documents that come out on the subject.
Garry Presthus ex (SEARO WPRO EMRO AFRO)
Manager MSU/SDE
Geneva,
[email protected]
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2. THOUGHTS: VVMS TO MANAGE THE COLD CHAIN AND IMPROVE VACCINE DISTRIBUTION
Debra Kristensen, PATH, unfortunately missed the Technet'99 meeting in
Harare. The use of the VVM as a proxy for other vaccines without VVMs has
been discussed and the Technet has rejected it several times, as each vial
of vaccine may have a different heat exposure history in the supply system.
Based on her long experience with VVMs, Debbie kindly posts her thoughts on
the use of VVMs as a management tool to the TECHNET forum.
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___________________________________________________________________________
From: "Kristensen, Debra"
To: "'Technet'"
Subject: VVMs
Date: Mon, 7 Feb 2000 09:28:56 -0800
Allan:
Hi! Here are some thoughts on how far we should go with VVMs to manage the
cold chain and improve vaccine distribution.
Debbie Kristensen
Technical Officer
Program for Appropriate Technology in Health (PATH)
4 Nickerson Street, Seattle, WA 98109-1699 USA
Telephone: (206) 285-3500; Fax (206) 285-6619
E-Mail: [
[email protected]]
[email protected][/email]; PATH Web Site:
http://www.path.org
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Use Of Vaccine Vial Monitors To Decrease Vaccine Wastage And Identify Cold
Chain Problems
I've learned from my colleagues that these ideas were discussed at Technet,
but not fully resolved. Here are some thoughts on the matter in an attempt
to advance the dialogue and perhaps reach resolution.
Background - The most important use of a vaccine vial monitor (VVM) is to
prevent administration of heat-damaged vaccine at the point of use.
However, VVMs can also be used to decrease vaccine wastage and identify
cold chain problems and breaks. The following is a quick overview of the
potential pros and cons of emphasizing these uses of VVMs.
1. USE OF VVMs TO DECREASE VACCINE WASTAGE THROUGH IMPROVED DISTRIBUTION
PROPOSAL: Health workers and stock managers can minimize the discard of
heat-damaged vaccine by comparing the colors of VVMs on available stock as
part of the decision-making process for distribution.
EXAMPLES INCLUDE:
* Sending vials of vaccine that have received the least amount of
heat-exposure on long outreach trips or to remote sites with low volume
immunization sessions.
* Immediately using vials of vaccine with VVMs near match point or sending
them to health care facilities that can quickly use them, if possible.
DISCUSSION: Instructions on the above are included in the original and
revised WHO training materials on VVMs. Using VVMs in this manner is a
natural "next step" as health workers become familiar with the technology.
One potential disincentive for stock managers is that they will need to
open boxes to view VVMs on vials.
RECOMMENDATION:
The use of VVMs to improve vaccine distribution and decrease wastage should
be encouraged.
2. USE OF VVMs TO IDENTIFY GENERAL COLD CHAIN PROBLEMS
PROPOSAL: The documentation of VVMs that have reached discard point at any
point in the cold chain could be used as an indicator of cold chain
problems. The discard of large quantities of vaccine due to VVM color could
be cause for cold chain investigation. Such information will also be useful
in making decisions regarding appropriate cold chain equipment selection.
FOR EXAMPLE:
* Stock managers or health workers could log quantities of closed vials of
vaccine discarded due to heat exposure as indicated by VVMs.
DISCUSSION: Quantities of vaccine discarded should always be documented
along with the reason for the discard. Partly used vials discarded provide
an indication of administrative wastage and closed vials discarded provide
an indication of cold chain wastage. It is a small step to include
"discarded due to VVM color" on current forms. This information would then
be available for supervisors to review. Large quantities of vaccine
discarded due to VVM color would be cause to investigate the cold chain for
equipment, maintenance, and training problems. VVM wastage data can show
whether or not lower cost equipment, e.g., domestic refrigerators, are
acceptable in particular cold chains.
Health workers and stock managers may be reticent to state that VVMs have
reached discard point while the vaccine was in their care for fear that
they will be blamed for the preventable loss of vaccine. Training must
therefore reinforce the fact that those who discard heat-damaged vaccine
are really "heroes". The act of discarding vaccine that is heat-damaged
should also be simplified to quickly move bad vaccine out of the system so
that it isn't inadvertently used.
RECOMMENDATION: The use of VVMs to identify general cold chain problems
through wastage data collection should be encouraged and included in the
VVM training materials.
3. USE OF VVMS TO MONITOR EVERY SEGMENT OF THE COLD CHAIN
PROPOSAL: Because VVMs log cumulative heat exposure and change color
gradually, they can sometimes be used as tools to identify problems with
specific parts of the cold chain.
FOR EXAMPLE:
* VVMs could be placed on the outside of each box (secondary packaging) and
on the outside of the shipping carton of vaccine along with forms for
documenting the status of the VVMs at each stage of the distribution chain
(receipt and dispatch at central and regional stores and each health care
facility). There was some discussion at the Technet meeting about using
this format to replace Cold Chain Monitor cards.
DISCUSSION: The use of VVMs to monitor every leg of the cold chain is
problematic because of the following issues:
* A VVM placed on the outer shipping carton would not represent the true
heat exposure status of the vials within. The Cold Chain Monitor Card has
to be activated to begin working. VVMs begin working immediately when they
are removed from -20 degree C storage and are placed on the vial labels
or caps. Therefore, a VVM placed on the outer carton at the time of
shipping would lag behind the inner VVMs and would not serve as a good
surrogate indicator. Of course a more sensitive VVM could be placed outside
the package, but this would add cost and complexity.
* Like the Cold Chain Monitor Card, a VVM on a box will only be relevant
until the point in the cold chain at which the vials are removed from the
box
* Vaccine manufacturers are already reluctant to add VVMs and are unlikely
to embrace the idea of further packaging changes.
* Compliance in using Cold Chain Monitor Cards has never been good and
is unlikely to be different with this system.
* Cold Chain Monitor Cards identify threshold temperature breaks above
10 degrees C. Depending on the length of the break, the VVM may or may not
register this infraction. The importance of this issue depends on how much
vaccine manufacturers rely upon Cold Chain Monitor Cards to guarantee the
quality of the first leg of shipping (for which they are responsible and
liable).
* This use of VVMs to monitor every leg of the cold chain creates a large
training burden and barrier to acceptance. Most health workers don't even
know how to read the four stages of VVMs yet. It seems prudent to
concentrate on the basics at this point in introduction.
ON THE OTHER HAND,
* Placement of a VVM on the outside of each small box of vaccine would
allow stock mangers to easily determine VVM status. The information could
be used for vaccine distribution decisions. Stock managers are unlikely to
use VVMs if they have to open each box of vaccine to view VVMs.
RECOMMENDATION: The idea of placing a VVM (or vaccine vial label with VVM)
on the outside of each small box of vaccine should be investigated for cost
and logistical implications. However, the addition of forms and procedures
to use VVMs to monitor each leg of the cold chain should be deferred or at
least put on the "back burner" until VVMs are globally available on all EPI
vaccines and their use is second-nature to those who handle vaccines.
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3. VVMS ON ALL VACCINES: COMMENTS FROM THE FIELD
The posting of these messages were delayed until enough came in, then
further delayed due to the pressure of other discussions. Apologies!
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___________________________________________________________________________
Date: Mon, 06 Sep 1999 00:00:11 +0300
To: Technet Moderator
From: "Prof. Msambichaka"
Subject: Re: Post0175 VVM NEWS!
This is really good news! Having VVMs on all vaccines will really change
children's immunisation.
Training and supervision are key to positive impact of VVMs ie reducing
wastage and reaching children in remote areas without cold chain
infra-structure. Therefore, training materials are now needed soonest.
When should they be expected for use in the field?
Khadija Msambichaka
---
Date: Wed, 11 Aug 1999 13:07:56 -0700
From: [
[email protected]]
[email protected][/email] (Robert Davis)
Subject: Re: Post0175 VVM NEWS!
To: Technet Moderator
Allan,
Do you know of any country studies which have been done on the savings made
by implementation of the open vial policy? An interesting subject, since
many countries have NOT implemented it to date.
Would this question be worth circulating on the Technet?
Bob D.
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