Vaccine Wastage

Re: Vaccine WastageThis is a point of great interest to the SolarChill Project as well. Thank you. Janos Maté

I think Mazella has touched a very important issue. I have always been worried about the freeze sensitive vaccines in areas where the temperatures are way below freezing for half of the year. The staff tend to prevent vaccines from freezing by just putting old quilts on the refrigerators because there is hardly any energy to heat them let alone for the vaccines. Then there are refrigerators with malfunctioning thermostats and dial/straight thermometers. I have never seen a freeze tag being used in any of the refrigerators that I have examined over the years at the service delivery points. We do not have a vaccine its management information system that reports vaccine wastage stratified in to causes. All we get is the number received, the number used and the number remaining. We do get immediate feed back if a store receives vaccine with VVM in late stages. There is lot of voice for that, but none for frozen vaccines. I have hardly seen any one carrying out freeze test during their supervisory visits. though all examine the VVM of all types of vaccines in the cold storage. I do see some monitoring reports mentioning the presence of frozen vaccines in some of the fixed EPI centres, specially TT vaccine. (May be it is easier than Penta to see), but then these reports are not kept in any orderly manner so that we can easily gather/collate the information. The only way we can get an (estimated) information on vaccine wastage is to carry out a cross sectional study. I would love to be part of such collaborative study. [indent][/indent]

PATH's website has a pretty comprehensive bibliography on this: http://www.path.org/files/TS_cc_evidence.pdf And here is the link to a recent study in PNG on the subject : http://www.savsu.com/resources/Case-Studies/PNG%20copy.pdf Tasnim

Vaccine wastage due to freezing temperature in the cooler or vaccine cold box/carrier is not easy to detect or identify compared to the vaccine wastage due to exceeded expiry date or VVM change to stage 3 or 4. Vaccine wastage (due to freezing temperature) is happening at all levels of the cold chain system but these are not documented or quantified. In many cases undetected frozen vaccines are still being administered. At present freeze tag indicators and fridge-tags are available. Shake test method was developed to determine whether vaccines that were subjected to freezing temperature are still safe to use. However, it has been observed that freeze indicators and shake test method are rarely used in the field. With the introduction of many new freeze sensitive and expensive vaccines in EPI, ways to prevent vaccine from freezing should be improved/ developed. Freezing of vaccines could possibly occur inside the refrigeration cooling equipment (walk in coolers/refrigerators) and vaccine cold box/carrier with frozen icepacks; and at extreme low ambient temperature. It is the refrigerant compressor thermostat that ensures the correct temperature inside the cooler or refrigerator. Improvement then should focus on this cooler/refrigerator component. There are still many functional vaccine coolers/refrigerators in the field that are equipped with adjustable thermostat. Is it possible to change these thermostats to a non-adjustable type so that users could not change its settings? To ensure that the correct storage temperature of vaccines is attained at all times, can thermostat and thermometer be calibrated in the field? If these devices cannot be calibrated in the field can these be included as part of service maintenance and be replaced at a certain period? Vaccine freezing usually occurs when unconditioned frozen icepacks are used in cold box or vaccine carrier. Guideline on conditioning ice packs was developed but oftentimes this is not practiced by health workers. Is it possible to design an insulated divider in cold box and vaccine carrier to ensure that vaccines are not in contact with the frozen icepacks? Vaccine refrigerator/ cooler with functional thermostat can maintain the correct vaccine storage temperature even at the ambient temperature below the freezing point. Freezing problem occurs when freeze sensitive vaccines are transported out of the refrigeration equipment and kept in the cold box or vaccine carrier. Can a wrapping material with excellent insulation properties be developed and used to pack the vaccines?

Dear Colleagues! Wastage of vaccine by freezing is horrible in my country (Russia). It's much more important than heating. First of all, a huge part of Russia has winter (air temperatures below 0 C) for 7-8 months. And, as the result, most of the shipments come to clinics already frozen. As the rule it happens on the ramp (in airport). Second problem - old fridges and errors of storage practices (no water bottles in fridges, not properly installed thermo regulator, no well qualified personnel). And the third - "amber light - stop" it means that the vaccine can be discarded if the temperature is below +2C (not 0 C) in accordance with Russian sanitarian rules. Does anybody know what happens with the vaccine if the temperature of transportation was +1,5 deg C? In Russia nobody knows, but everybody is afraid to use the vaccine - because in sanitarian rules of transportation and storage we have a string - "+2 ...+8 deg C, otherwise - discard!" In my experience up to 70% of the clinics (3-4 level) have these problems. It become better when personnel start to use fridge-tags, and after explanation of storage practices (WHO how to). Shake-test is still unknown in Russia and there are no approved methodis in Russian. I don't know about official statistics of vaccine wastage in Russia, but according to IMHO it's about 75%! 35-40% happens on 2-3 level. 35% on 3-4 level. What we do: 1. Study, Study and one more time Study! Personnel is the first. 2. Test fridge before use. We recommend to test fridge with data logger before we use it. 3. Use Matryoshka" (nested doll) method when preparing winter shipment ( it means vaccine -> package -> cardbox-> coldpack->cardbox ->warmpack->PU or EPS container) for long distances. 4. Use insulated pouches or cardbox for 2-5 hour shipments on 3-4 level ( it means vaccine -> package ->pouche (cardbox)-> coldpack -> container)

There are still many functional vaccine coolers/refrigerators in the field that are equipped with adjustable thermostat.  Is it possible to change these thermostats to a non-adjustable type so that users could not change its settings? 

Absolutely agree. Automatic thermostats are much more useful then manual! I know a lot of cases when a big quantity of vaccine was delivered to the clinic, and the personnel change by themselves the settings of thermostat (because they are afraid of heating) and then forgot about it. So the vaccine become frozen in the night. P.S. Sorry for my English.

Interesting videos on shake tests: Shake test: [vimeo]8381355[/vimeo] Shake test educational video: [vimeo]8389435[/vimeo]

Please also refer to the award-winning research article Use of cool water packs to prevent freezing during vaccine transportation at the country level, authored by Umit Kartoglu, Serge Ganivet, Stephane Guichard, Venkat Aiyer, Peter Bollen, Denis Maire and Birhan Altay, in the documents section of our website.