POST 00228 : SLOW CHAIN & FAST CHAIN & VVMs

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. Send your messages, contributions and postable files to: [[email protected]][email protected][/email] ____________________________________*______________________________________ 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. Action, comments and additions please: [[email protected]][email protected][/email] or use your reply button ___________________________________________________________________________ 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] ____________________________________*______________________________________ 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. Action, comments and additions please: [[email protected]][email protected][/email] or use your reply button ___________________________________________________________________________ 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 ___________________________________________________________________________ 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. _________________________________*_________________________________________ 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! Action, comments and additions please: [[email protected]][email protected][/email] or use your reply button ___________________________________________________________________________ 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. ____________________________________*________________________