Cold Chain Routine Immunization

COLD CHAIN : 

COLD CHAIN Dr. Vinay

Discussion : 

Discussion What is cold chain? Importance of cold chain Equipments of cold chain Vaccine sensitive to heat, freeze & Light Ideal methods of utilization Cold chain monitoring Field Facts

Slide 7: 

What is the Cold Chain? Cold Chain is a system of That keeps vaccines at right temperatures to retain potent from place of manufacturer till it is administered to the beneficiary

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Why have the Cold Chain? If vaccines are exposed to excessive They lose their potency

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In general All Vaccines lose potency on exposure to heat above +80 C Some Vaccines lose potency when exposed to freezing temperatures The damage is irreversible

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Vaccines vulnerable to heat BCG (after reconstitution) OPV Measles HepB DPT DT BCG (before reconstitution) TT

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Vaccines vulnerable to Freezing Hep- B DPT DT TT

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Summary of Vaccine Vulnerabilities

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Cold Chain Equipment: Various Levels –State

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Cold Chain Equipment: District Level

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Cold Chain Equipment: Planning Unit Level

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Transportation of vaccines from Regional centers to districts From districts to PHCs Temperature maintained at +2o to +8o C. 2. Refrigerated Truck

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1. Walk-in Cooler & Freezer Walk-in Cooler (+2o C to +8o C)

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4. Deep Freezer (DF) Size: 300 ltr / 140 ltr Level: District (300 ltr) / PHC (140 ltr) Temperature: -15o to -25o C Utilization: Preparation of ice packs Storing measles and OPV (only district) Holdover time: 4 hours Storage capacity: 300 ltr: 150, 000 to 200, 000 doses 140 ltr : Approx. 20 Ice Packs

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Other accessories to Walk-in Cooler & Freezer

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The Cold Chain Room ILRs and deep-freezers to be installed in a room that is Not directly exposed to sunlight or any other source of heat. Ventilated and protected from rain or flooding. ILR and deep-freezers should be level, on wooden blocks, at least 10 cms away from wall The plugs should be permanently fixed & labeled “DO NOT REMOVE” Equipment should be locked and opened only if necessary Keys to the equipment should be accessible

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3. Ice-Lined Refrigerator (ILR) Size: 300 ltr / 140 ltr Level: District (300 ltr) / PHC (140 ltr) Temperature: +2˚C to +8˚C Utilization: BCG, DPT, OPV, Measles, TT, Hep-B vaccine Holdover time: 14 hrs after 8 hrs continuous power supply Storage capacity: 300 ltr: 60,000 doses of mixed antigen & 20,000 doses of OPV 140 ltr : 25,000 doses of mixed antigen & 18,000 doses of OPV* * OPV and Measles for 1 month only. Store in DF if longer than a month

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5. Cold Boxes Size: 20 ltr and 5 ltr Level: District / PHC Temperature: +2˚C to +8˚C Utilization: All vaccines can be stored for transportation or in case of power failure Holdover time: 5 days (20 ltr) and 3 days (5 ltr) if unopened Storage capacity: 20 ltr: 52 Ice Packs & 6000 doses of mixed antigens 5 ltr: 20 Ice Packs & 1500 doses of mixed antigens

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6. Vaccine Carriers Size: 1.7 ltr Level: PHC/ Sub Centre Temperature: +2˚C to +8˚C Utilization: All vaccines can be carried in small quantity for vaccination sessions Holdover time: 12 hours Storage capacity: 4 Ice Packs &15-20 vials of mixed antigens

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7. Ice Packs Size: 763 X 90 X 33 mm Ice capacity: 360 ml Weight: 80 gm Level: District / PHC/ Sub Centre Temperature: +2˚C to +8˚C Utilization: line the walls of vaccine carrier/cold box Time to Freeze: 48 hours in DF at - 20˚C

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8. Foam Pads Material: Soft Foam Thickness: 30 mm with at least 6 incisions Utilization: temporary lid for unopened vaccines inside the carrier surface to hold, protect and keep cool opened vaccine vials

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How to use an Ice-Lined Refrigerator (ILR) Setting Ice-Lined Refrigerator (ILR) controls Packing an Ice-Lined Refrigerator (ILR) Part 2

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Setting Ice-Lined Refrigerator (ILR) controls turn OFF the ice-lining switch (if there is a switch), Adjust the thermostat: Set the thermostat to 1 ( highest temperature setting) , and tape. If after 3 days the temperature is less than 2°C at any time, reduce thermostat to MINIMUM power setting. Do not adjust the thermostat after power cuts or if the temperature occasionally rises above 8°C.

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Verify Daily the Temperature of the Cold Chain Storage at the Health Centers and Out Posts Thermometer +2°C to + 8°C DPT,DT & Tetanus Toxoid OPV (Polio), BCG, Measles, 0°C -15°C to -25°C Stored together in ILR Ice Packs in deep Freezers

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Right way of keeping vaccines in ILR Same vaccines in same area. Diluent / freeze sensitive/ Closer expiry date vaccines on top Heat sensitive / Further expiry date vaccines in the bottom of basket

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Full ILR cannot maintain potency of vaccine

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Do not open lid of ILR too often

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Discard Frozen DPT, DT and TT vials

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How to use a Deep Freezer (DF) Freezing ice-packs in a deep freezer Freezing ice-packs in a deep freezer To prepare icepacks place about 27 icepacks in a cris-cross manner. They will be frozen at -20o C for 48 hours. Leave 10-mm spaces between icepacks After a session put the ice-packs back in the freezer.

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Freezing ice-packs in a deep freezer

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Overfilling Deep Freezer damages equipment

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Preparing icepacks for use: Filling and Freezing Fill icepacks with water to mark Fit the sealing plug and screw on the lid tightly Hold each ice-pack upside down and squeeze it to make sure it does not leak. Place the icepacks in the deep freezer. Ice-packs need not be refilled every time they are used. The same water can be used repeatedly. Do not use saline water for filling

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Preparing icepacks for use: Conditioning On the session day, take the frozen ice-packs you need from the freezer and place on a table Allow ice-packs to sweat at room temperature for 15 minutes Shake the ice pack to listen to melted for water.

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Loading a Vaccine Carrier Put conditioned ice-packs against each of the 4 sides of the vaccine carrier Take required vaccines and place them inside a plastic bag and place bag In vaccine carriers, place a foam pad on top of the conditioned ice-packs. Close the cold box or carrier lid tightly. 2 3

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Never use Day carrier

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Never put vaccines in direct touch with Ice packs

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Never place vaccines on ice-packs in sessions

Maintenance of Equipment : 

Breakdown/Repairs: Early reporting & timely repairs is good cold chain management. Handy spares reduces down time & speeds repair. Condemned units to be removed/ replaced by standby units. Contingency/Emergency Plan: Identify alternate storage points incase of equipment failure. Funds approval, manpower & mobility to be geared up in advance. Maintenance of Equipment

Power Factor : 

Generator: Standby power back up facility- diesel generators of capacity 7.5/10 KVA Voltage Stabilizers: An essential safeguard of 1 KVA capacity connected to all Freezers & ILRs to combat unstable electric supply voltage Servo Stabilizers:A voltage fluctuation stabilizing device connected for safety to all Walk-in-Freezers & Walk-in-coolers Power Factor

Voltage Stabilizer : 

Capacity: 1.0 KVA Incorporates: High & Low Voltage cut off with 6-9 minutes switch on delay Input Voltage: 150-280 volts Output Voltage: 220 ± 75 Voltage Stabilizer

Vaccine Distribution & Re use : 

Vaccines are not stored at the sub-centre level and must be supplied on the day of use Note manufacturer, batch no., VVM status WHO pre qualified vaccines should be used for SIAs mOPV for selected areas in Western UP, Bihar, Mumbai/Thane Use VVM stage-II vaccine near the cold chain point (do not distribute to remote areas) Partially used OPV vials can be returned to the field the next day, if the VVM has not reached discard point Vaccine Distribution & Re use

Return of vials and reuse : 

Return all used and unused vials to PHC Match OPV consumed with children immunized See VVM of unused vials Replace stage-I and II vials in DF/ILR after marking them / separately packing them Use returned vials first on subsequent day after checking VVM Ensure OPV is not left in VCs at the end of the day Re-evaluate requirement of teams and rationalize distribution Return of vials and reuse

Vaccine Basics............. : 

Follow First-in-First - out rule (FIFO) Also: First to expire - First out. (FEFO) T series, Hep B and Hib and diluents should never be frozen. BCG, OPV & Measles (light) are sensitive to heat & lose potency fast. Potency lost due to heat exposure does not change the appearance of the vaccine. VVM is an effective tool in monitoring OPV potency. Damage to vaccine cannot be reversed by re-freezing. Discard frozen T series vaccine & Hepatitis B Vaccines. Vaccine Basics.............

SOME FIELD FACTS! : 

SOME FIELD FACTS!

Presence of all 3 types of OPV at Planning units long after completion of SIA rounds : 

Presence of all 3 types of OPV at Planning units long after completion of SIA rounds mOPV 1 mOPV 3 tOPV Stage 3 vaccine Return all monovalent OPV to DHQ after the round.

Vaccine Management…….. : 

Vaccine Management…….. Different batches of vaccines mixed with missing labels Mixed Vaccine Vials with missing labels

Vaccine Potency……… : 

Vaccine Potency……… 2 batches of OPV mixed with vial in 3rd stage

Vaccine Potency……….. : 

Vaccine Potency……….. Frozen DT at bottom of ILR

Vaccine delivery : 

Vaccine delivery Vaccine carrier lying in area 5 days after SIA completed Vaccine left in carrier after activity

Preparation & Storage of Ice Packs : 

Preparation & Storage of Ice Packs

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Polio team !!!

Monitoring…………. : 

Do we maintain Temperature Chart? Do we have sufficient Cold Chain Equipments(ILR/DF/Vaccine Carrier/ice pack)? Is the vaccine potent & the one recommended? Do we maintain daily stock of vaccine distributed during SIA? Do we have vaccine delivery plans(Route) in place? Do we have an ice packs freezing plan? Do we make provisions to resupply ice packs? Do we supply sufficient ice at regular intervals to teams? Do we return balance stock of mOPV to DHQ? Do we ensure return of all Vaccine Carriers with all ice packs to PHC (SIA/RI)? Do we maintain all Cold Chain equipment at its optimum level? Monitoring………….

Slide 58: 

Vaccine Vial Monitor (VVM) The square is lighter than the circle. If the expiry date is not passed, use the vaccine The square is lighter than the circle. If the expiry date is not passed, use the vaccine The square matches the circle. Do not use the vaccine. Inform your supervisor The square is darker than the circle. Do not use the vaccine. Inform your supervisor

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Minimizing vaccine wastage VACCINES ARE EXPENSIVE! DPT = Rs 1.30 per dose TT = Rs 0.66 per dose DT = Rs.1.30 per dose OPV = Rs 8.00 per dose Measles = Rs 8.34 per dose BCG = Rs 1.50 per dose Hepatitis B = Rs 17 per dose

THANK YOU!!!!!!!! : 

THANK YOU!!!!!!!!