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The Cold Chain

In this video, S.D. Gupta describes how maintaining the cold chain has been of critical importance to the global polio eradication effort. (Step 3.5)
SD GUPTA: Now, one important component of the logistics management and also the polio eradication program was cold chain. Maintenance of cold chain was of critical importance. And if this cold chain is not maintained, or it breaks down during the distribution, storage and distribution, the efficacy of the vaccine will be reduced or may be lost. So this cold chain is a very important part of this, this supply chain levels, right from manufacture to the national vaccine stores, the state level vaccine stores, regional stores, and then district level and block level vaccine stores, and then outreach trials of [INAUDIBLE] We need– so this vaccine has finally to be carried by the health care workers. You can see this picture.
This is a van, and this is the [INAUDIBLE] cold box or vaccine carrier where they are taking the supply to a primary health center from district level. This picture is from Afghanistan. And this is how– this cold chain is a very important link in the supply chain. So maintaining cold chain was very, very important. And this, keeping the vaccine at the right temperature, was very, very important, because this other polio vaccine is heat labile. Its efficacy goes down. Therefore, it has to be kept on prescribed [INAUDIBLE] or prescribed temperatures to maintain its potency and efficacy. Now, safeguarding this vaccine. I have said that this has to be potent, and safe, and how do we do this?
As you know, this cold chain. Now, what do we need? Now, maintaining cold chain, we need the workforce. Remember your supply chain is as good as your human workforce. If they are not competent, if they are not skilled, they are not trained, they are not motivated, and they are not available, then the logistics of their safeguarding of the vaccine will be very difficult. So we need to have right persons who are very trained at all levels of storage and supply of the vaccine, and then, at the health facility level, during transportation from health facility to the vaccination site. So the personnel are very, very important– well-trained personnel, committed personnel are very important for safeguarding the vaccine.
And one of the sections is all the leftover vaccines, what to do with them, and how to procure vaccine for the next session? How to dispose of the unfinished vials of the vaccine? All these are very, very important procedures. We require equipment, as I have mentioned earlier, and I was talking about the commodity. You need reserves. You need continuous electricity supply. You need other equipment like cold boxes, vaccine carriers. You needed the ice-lined refrigerators. All these are very proven. And then, vaccine vial monitors. Because in the villages, you might not be able to maintain the temperature or monitor the temperature while it is being transported from healthcare facility to the vaccine site or in the health facility itself.
Because that is in a remote area, and the [? laxity ?] supply may be disrupted often. So this is very important, that such equipments are available to also monitor whether the temperature is right. So vaccine vial monitors are used for seeing whether the temperature is fine. So we needed different recruitments to maintain cold chain and safeguarding the vaccine, and then the definitive procedures were described. [? All are ?] described, how the warehouses at the state level or the national level, what are the storage procedures? What are the inventory management procedures? How the inventorying is done? How it is supplied?
How this is– so these are the procedures that have to be described in the guidelines for safeguarding the vaccines of the nature of oral polio vaccine– it’s so heat labile. So this is a very important component of logistics management and supply chain, especially in an immunization program. A whole lot of coordination is required between and among these levels, so that supply chain is smoothly functioning. Sometimes there are invoices going up to the national level for supply of certain quantities, and they are not responding. There may be stockouts, or the staff is on leave, or somebody is not in the warehouses. So a lot of coordination is required.
The coordination at the national and regional levels, and then regional and provincial levels, and from provincial levels to district nodes, and from district level to primary health care level. So this coordination is very, very important. So a well-planned campaign ensures that essential cold chain and logistics steps are considered in a timely and well-coordinated manner before, during, and after the campaign. You will see this is the storage facility at the national level. And you will find how these– you can see the air conditioners maintaining there, and then we have [INAUDIBLE] refrigerators which have been there, how the logistics is managed, how they are stored and inventories are properly managed. And on the right, you see this beautiful health care worker.
She is leaving the health facility for vaccination. And you can see the blue box with her, cold, and it’s a vaccine carrier. And it is lined with ice packs to maintain the temperature inside, and vaccine is kept on low temperatures while used at the end user level. So that is the kind of thing that was adopted and developed in immunization programs. So as I said in the beginning, if you have product, right product, in right quantity, at right time, at right place, to right user, that is very, very important– and right conditions. It should reach the end users so that it is effective in achieving the program goals. I mentioned about the vaccine vial monitors. What is this?
So see, this monitor would tell you the cumulative heat exposure. So the VVM is put on the vaccine carrier, or inside the vaccine carrier, and then it gives you the signal green. It says, if it is green, use this vaccine. This comes up, will come only when the vaccine is at the right temperature. And then you will see, if it is not maintained at the right temperature, it will give you a signal that it is no more usable and discard this batch. So this red color– don’t use the vaccine.
Now, this device was developed for the field, that one, because the health care worker does not have and she or he is carrying on his back along the shoulder in a vaccine carrier. So this vaccine vial monitor will tell you you are getting the vaccine at the right temperature. Very important logistics part of polio program. If the vaccine has lost its potency due to non-compliance of the temperature maintenance, then it will not be efficacious. And again, if you want to eradicate polio, it will not. And what we need to understand– what are the anticipated problems and challenges at each level in the cold chain and/or supply chain? For example, you know what happened?
There was no vaccine supply in the country. Now, therefore, the whole campaign suffered because they changed the vendors. So vendor assurance and vendor confidence is very, very important for supply chains, though right? Starting from the policy level, and then centrally warehousing, what are the problems? What are the challenges? And down the line, regional warehouses, transportation from national warehouse to regional warehouse, what are the issues and challenges regarding transportation, of cold chain, or storage? All these are issues that may pose challenges at each level. So going from forecasting, indenting, storage, reporting, transportation, distribution of the vaccine, then monitoring and demand estimation, now, in the group, we should discuss what are the problems and challenges at each level?
Well, some of the things, like forecasting, is done at the national level. The demand forecast is done on the national level by the policy makers and program managers, and maybe, also, at the state level, where they do their forecasting. And then they indent accordingly from the national level. Now, what are the issues in indenting, delays in indent, or reaching indent, or submitting supplies. So there may be problems with the storage. And what we found in the beginning, storage, especially in the warehousing, was a very, very difficult thing. So there were no [INAUDIBLE] warehouses at the district level. So where do we store it? So they went to the private storage.
Now, private storage, like other storage of the commodities for which they were doing business, they were also keeping vaccine with that. So our control was not that much. So this storage created a lot of problems in the beginning, but later on, it was sorted out. And then reporting, the logistics, supply, procurement, use, consumption– all this information. There are a lot of glitches that happen in reporting of the vaccination site, the performance, attendance, use of vaccine, waste of vaccine, and all that.
There is use of the transportation, and this transportation was a major issue from district level to the primary health care level and from primary health care level to the vaccination site in which you are doing it in the campaign mode. So transportation was a major challenge at the primary healthcare level, because the transport might not have been available, or waited for it, or breaking down of the transportation. Because they were going along the supply chain distribution, and they will go to several campaign sites, and there may be delays in supply because of the transportation and all that. So there are, then, issues related to distribution and monitoring.
There may be challenges related to vaccine storage, then freezer rooms with optimum storage capacity in the rural areas, and then monitoring and reporting on the vaccine storage [INAUDIBLE],, using warehouses not meant for storage because we used private sectors, and the private sectors were using their warehouses for their own commodities. They were requested to keep the vaccine as well. That control was not there. And then the supply of vaccine carriers, and ice boxes, and timely availability of ice boxes. And with the ice boxes, now I understand that these are flat [? boxes. ?] And what we’ll do is, after returning from the site, we’ll fill up with– keep them back in the freezer, so where the ice is made.
And the next day, when we move out, we put these ice boxes, again, in the vaccine carriers. So there are problems. And if the electricity was not there, the ice boxes will not be ready. And if they’re not ready, how to carry the vaccine? But this you learn only when you do it yourself. You will face these issues. So I’m sharing with you all these because, as a young professional, and managing a primary health center, and then, at the state level, coordinating the program, I really got deeply into the challenges and issues and solving those problems. Therefore, I am talking to you in quite great details about what happened, really, at different levels.
So another important thing was a shortage of human resources and training, especially regarding cold chain maintenance. Giving drops of polio vaccine to the child is fine, but maintaining cold chain at all levels requires a special training. And then, faulty equipments, and then maintenance of the recommended temperature, interrupted electric supply, and breakdowns in temperature in rural areas, monitoring to ensure and safeguard vaccine quality, and storage facility to session activity. Maintaining cold chain was not that easy for [INAUDIBLE].. So these are some of the challenges. But finally problem is sorted out. New solutions were created to deal with these problems. So it evolved, and finally, the goals could be achieved.
So as I discussed earlier, there were many challenges to logistics and supply chain or vaccines, and there were solutions that were found out and implemented by countries. Like in India, the Ministry of Health and Family Welfare, in partnership with UNICEF, developed a map-based origin information system to monitor the cold chain system in real time across the country. So we would know, in real time– this was a GPS system that was created online. And we were able to monitor the cold chain information all through the country, down the line, in the field conditions. So innovations took place. And then, supply of vaccine.

Dr. S.D. Gupta, M.D, Ph.D, FAMS Chairman, IIHMR University, India

Maintaining the cold chain has been of critical importance to the global polio eradication effort.

Across the immunization supply chain (outlined in slide 11), at which level might it be most challenging to maintain the cold chain, and why?

Please post your answers in the discussion forum.

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