TechNet-21 - Forum

This forum provides a place for members to ask questions, share experiences, coordinate activities, and discuss recent developments in immunization.
  1. Chris Wright
  2. Supply chain and logistics
  3. Wednesday, 04 November 2015

Recently, I was sitting with the Expanded Programme on Immunization (EPI) Manager, his senior staff, and technical assistance (TA) partners in an African country, discussing support for better visibility and analysis of immunization supply chain data. The EPI Manager was willing to listen, but wasn’t sure his team needed help in data analysis. As for visibility, that was already being addressed: they using a web-based inventory management system that, among other things, providecold chain volumetric data (total capacity and used capacity). As we discussed plans to deploy the online tool at the district level and in facilities with internet connectivity, I asked if data was also collected on the other, non-EPI commodities that we know are often stored in the cold chain: some lab reagents, certain antiretroviral medicines, oxytocin, insulin, etc. The team seemed surprised by the question; “those aren’t our commodities,” the program logistician explained. True, I replied, but they do frequently take up room in the fridges (even if only in the short-term), so if it isn’t captured as part of inventory, then your volume data won’t give you the true picture of what percentage of capacity is really being used...

Read the complete blog post here

References
  1. http://thepump.jsi.com/cold-chain-policy-vs-cold-hard-reality-thinking-inside-the-box/
Chris Wright Accepted Answer

Raja asks some great questions. The answers are many, but they start with:

  • Data: We need to understand the total number of temperature-sensiive products by SKU in the various supply channels that will (or should) converge at the SDP and that need to be stored in CCE; this will vary by country, program, disease profile and STG. We need to know the volume of the primary unit of packaging, as well as secondary packaging and carton, for each SKU.
  • Quantitification: We need to understand what the monthly demand and throughput is of each SKU at each supply chain tier, but most especially at the SDP where space constraints are likely to be most acute.
  • Modeling: Using the product data and quantification, we need to model optimal volume capacity at each supply chain tier, and especailly understand volume requirements at the SDP by different service level profiles (rural health post serving a catchment population of 5,000 vs. urban health center serving 20,000).
  • Standardization: We need to standardize and "right-size"equipment not only to accommodate today's volumetric needs, but project a decade into the future to ensure we have sufficient capacity to accommodate new vaccines now in the development pipeline.
  • Labeling: We need global agreements on labeling by color code or other visual cues so that primary packaging is clearly marked.
  • SOPs: We need standards for segmenting integrated CCE by product type in order to train HCWs on safe and effective CC inventory management and handling.
  • Training: Well, this is pretty self-explanatory...

I'd love to continue this conversation and see what others think I've missed, and then work with WHO, UNICEF and partners to develop some practical guidelines and standards to be used in CCE integration.

Chris

JSI

  1. more than a month ago
  2. Supply chain and logistics
  3. # 1
kamal Accepted Answer

great effort .

  1. more than a month ago
  2. Supply chain and logistics
  3. # 2
Patrick Lydon Accepted Answer

Agree. All great questions. Many of which are still, largely unanswered.

From my own experience and limited exploration into this, the trend is clear. Many countries are already storing vaccines with other time and temperature sensitive pharmaceuticals (not just Oxytocin). Several of us are currently in Sri Lanka for the UNICEF workshop on Immunization Supply Chain Strengthening for South Asian countries. We had the opportunity for a field visit yesterday to learn from the Sri Lankan system. While vaccines are stored separately at national level and managed by the EPI unit, all health commodities converge under one roof at regional level. From then on, the supply chain is integrated. The photo attached shows Oxytocin stored right underneath TT vaccine at a regional cold room. The cold room had at least 50 different time and temperature sensitive pharmaceuticals together (including animal vaccines).

Whether we have all the evidence at international level and answers to all these questions, countries are already moving forward. To a certain extent, I feel the convergence train has already left the station. But one cannot over-emphasize the need for healthcare workers to organize and clearly label all products being stored in the fridge at health center level. This is why the 2015 revision of the Immunization in Practice manual from WHO makes the point quite clearly in Module 2 (attached) around the vaccine cold chain. On p.27 on arranging products in the fridge, the mention below is made in bold: If other heat-sensitive supplies, such as drugs, ointments, sera and samples, have to be stored in the refrigerator, label them clearly and keep them completely separate from the vaccines and diluents”. As more and more products are (and will continue to) be creeping into the vaccine refrigerator, more work will be needed on visual cues and approaches to train health workers in order to mitigate the risks of mixing up health commodities stored in the cold chain.

I encourage others in the TechNet Community to voice their views on this topic!

Patrick (from Colombo)

Attachments (2)
References
  1. http://www.who.int/entity/immunization/documents/IIP2015_Module2.pdf
  1. more than a month ago
  2. Supply chain and logistics
  3. # 3
Emily Bancroft Accepted Answer

These are all great questions. I know the UN Commision on Life Saving Commodities for Women & Children looked at many of these issues during their research on integrating oxytocin into the cold chain. PATH published a good overview document when can be found on the Life Saving Commodites website at http://www.lifesavingcommodities.org/wp-content/uploads/2014/09/Oxytocin-brief.pdf. Although this doesn't answer all the questions, it's a good starting place for countries and a good companion piece to the WHO/UNICEF Joint Statement.

 

References
  1. http://www.lifesavingcommodities.org/wp-content/uploads/2014/09/Oxytocin-brief.pdf
  1. more than a month ago
  2. Supply chain and logistics
  3. # 4
Raja Rao Accepted Answer

This is a great discussion. Thanks to al for starting it. I couldn't resist asking a few questions:

1. What about the chances of gettng the oxytocin mixed up with a vaccine dilluent for lyo vaccines? I've heard many of these things look like diluent. And I suppose it's only a problem if HCWs keep diluent in the fridge - always or 24 hours before an immunization session?

2. What does the decison and implementation process look like to integrate immunization and non-EPI drugs into a cold chain system? What levels? What are the conditions that should be met? When does the volume capacity requirements/calculations get done in the integration example? When do countries do the volume capacity requiremennts in general to identify CCCE volume requirements?

3. Is integrating oxytocin with EPI vaccines the most program and cost efffective integration approach? Is there any evidence out there that provides countries with guidance on the top 5 or so way to immprove the efficiency and effectiveness of health supply chains through integration?

Thanks,

Raja

  1. more than a month ago
  2. Supply chain and logistics
  3. # 5
Chris Wright Accepted Answer

Michel, thanks for the tip on the joint statement. I participated in the original discussion about oxytocin in the cold chain, and am glad to know that a practical policy statement from these two leading agencies resulted. I suppose the trick is now to disseminate that statement more broadly. This is a good start.

Brian, thanks for making the point about the need to review CCL tools so that they are more comprehensive, taking into account the broader supply chain context and broader array of health products.

  1. more than a month ago
  2. Supply chain and logistics
  3. # 6
Brian Taliesin Accepted Answer

Nice post and response, Chris and Michel.

Often our cold chain sizing tools solely look at the capacity needs of the fully immunized child and neglect the other temperature-sensitive, life-saving products that converge at the health facility. And empowering the frontline health worker requires the national policy making support backed by better data.

Brian Taliesin, Systems Analyst for Digital Health Solutions, PATH

  1. more than a month ago
  2. Supply chain and logistics
  3. # 7
mpacque Accepted Answer

This post reminds me of an earlier discussion/posting (on TechNet http://www.technet-21.org/en/forums/oxytocin-in-the-cold-chain) which focused on "oxytocin in the cold chain".  That discussion was later followed up by a joint statement from WHO and UNICEF encouraging greater health commodity supply chain convergence for temperature-sensitive pharmaceuticals where appropriate.  I have attached the statement here, and hope that we no longer will talk or hear program managers talk about the "EPI-Cold Chain", as the statement clearly emphasizes that "WHO and UNICEF confirm that it is permissible to transport and store drugs in the vaccine cold chain, provided that best storage and labeling practices are adhered to at all times to clearly distinguish non-vaccine products from vaccines and diluents."

The statement can also be found at http://www.unicef.org/health/files/EPI_cold_chain_WHO_UNICEF_joint_statement_A4_rev2_5-14-15_(3).pdf

Michel

References
  1. http://www.technet-21.org/en/forums/oxytocin-in-the-cold-chain
  2. http://www.unicef.org/health/files/EPI_cold_chain_WHO_UNICEF_joint_statement_A4_rev2_5-14-15_(3).pdf
  1. more than a month ago
  2. Supply chain and logistics
  3. # 8


There are no replies made for this post yet.
Be one of the first to reply to this post!