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assessment of Cold chain Status for immunization in Central Ethiopia

assessment of Cold chain Status for immunization in Central Ethiopia. By Bezunesh Rogie Advisors: Professor Yemane Berehane (MD, MPH, PhD) Dr. Filimona Bisrat (MD, MPH) May, 2012. Outline of the presentation. 1. Introduction 2. Rationale of the study

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assessment of Cold chain Status for immunization in Central Ethiopia

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  1. assessment of Cold chain Status for immunization in Central Ethiopia By BezuneshRogie Advisors: Professor YemaneBerehane (MD, MPH, PhD) Dr. FilimonaBisrat (MD, MPH) May, 2012

  2. Outline of the presentation 1. Introduction 2. Rationale of the study 3. Study context/Area 4. Objectives 5. Methods 6. Results and Discussions 7. Strength and Limitation 8. Conclusions 9. Recommendations 10. Acknowledgement

  3. Introduction • Globally Expended Program on Immunization (EPI) was launched by WHO in 1974 against six childhood diseases: polio, measles, tetanus, diphtheria, pertussis, and tuberculosis. • Ethiopia had introduced EPI in 1980 with the intention of increasing the annual coverage by 10% and reach 100% coverage in 1990. • In the past decade, more efforts had been focused towards the increment of vaccine coverage, considered as one of the indicators to measure the success of immunization programs.

  4. Introduction con.. • Inadequate attention was given to address the issue of quality of vaccination that greatly depended on two main factors; • cold chain management that plays a great role for vaccine potency and • competence of health workers to manage the cold chain and administer safe vaccines for targeted groups. • Current global efforts towards eradication of vaccine preventable diseases can not be successful without due attention to the effectiveness of the vaccines.

  5. Rationale of the Study • Immunization is the most cost effective public health intervention that reduced the burden of infectious diseases globally. • However, for the effectiveness of immunization, in addition to the high coverage, availability, functionality and proper management of cold chain system and provision of safe vaccines are mandatory. • The routine immunization coverage in Ethiopia, particularly in big & agrarian regions; Oromiya, Amhara & Southern Nations and Nationalities has been on increasing trend for the last few years.

  6. Rationale cont… • On the other hand; some reports indicated the occurrence of outbreak of vaccine preventable diseases. • This study was, therefore, conducted to assess the status of cold chain and practice for immunization in public health facilities to recommend for development of appropriate strategies that will help for the improvement of immunization quality.

  7. General Objective • To assess the cold chain status and practice in 116 health facilities located in three CCRDA/CORE Group Ethiopia districts of Oromiya, SNNP and Amhara Regions of Ethiopia .

  8. Specific objectives • To assess status of cold chain in public health facilities • To asses knowledge of health workers on cold chain management • To identify factors associated with knowledge of health workers on cold chain management

  9. Methods and Materials

  10. Study Context/Area The study was conducted in three districts; • Bora (Oromiya), • Soddo (Southern Nations & Nationalities People)and • Basonaworana (Amhara) Regional States respectively. The common features of these districts were; • all are agrarian • supported by CCRDA/CGPP • relatively documented a good coverage of Penta 3 • located in the Central part of Ethiopia • At around 130kms distance to the south, south west and northern direction respectively from Addis Ababa(the Capital of Ethiopia)

  11. Study Design and Population Study design • An Institution based cross sectional study was conducted in 116 out of 117 public health facilities in selected districts in December 2011 and January 2012 using quantitative data collection tools. Study Population • All public health facilities which had been rendering immunization service and • All health workers that had been administering vaccination in the same facilities during data collection period

  12. Sample Size and Sampling Sample size for health facilities • 116 facilities renderingroutine immunization services were included for observation of cold chain. • 103 health posts and 13 health centers were included for direct observation of cold chain status Sample size for Health workers • The same number of health workers who had been administering vaccination during data collection period were observed for their practices and interviewed for their knowledge on the cold chain management and injection safety. (1 Health worker/facility)

  13. Pictorial presentation of Study Context and Sampling Procedure

  14. Data Collection tools and procedures Instruments • Structured close ended Questionnaires, and Observation Check Lists that were adapted from WHO were prepared in English and • Amharic version used for data collection Data Collectors • Experienced Health Officers and Nurses were recruited from facilities outside study areas to collect and coordinate data collection. • One data collector was assigned per health facility per day Data collection procedure • Routine immunization service providers approached at their facilities • Requested for their consent, observed for their practice and interviewed for their knowledge on cold chain and injection safety

  15. Data quality • Two days training including field exercise was conducted outside the study districts, • Data collection tools were pre-tested and reviewed to include the findings. • Daily check up on the content and quality of collected data was done

  16. Data Entry and Analysis Data Processing • Data entry and cleaning was handled by the data entry clerk and investigator using EPI-info version 3.5.1. • Then after, the data was exported to SPSS Version 16 for further univariate, bivariate and multivariate analysis.

  17. Data Entry and Analysis Cont… Data Analysis Procedure • Odds Ratio was calculated to test the degree of association between knowledge(dependent) and professional qualification, myears of experence on routine immunization and exposure to training on cold chain (independent ) variables at 95% Confidence Interval (CI). • As the outcome variable is categorical, logisticregressionwas used for controlling of potential confounders.

  18. Study variables The IndependentVariables were • Qualification (Professional background) • Year of service on immunization program, • In-service trainings The Dependent Variable was • Knowledge of health workers on cold chain management

  19. Operational Definitions • Unsatisfactory knowledge: Immunization providers those scored less than or equal to 21 points (below the mean score). • Satisfactory knowledge : Providers those scored greater than 21 points (above the mean score). • Knowledge about cold chain: Having an understanding on the existence of a network of refrigerators, cold boxes and vaccine carriersto keep vaccines at the right temperature range (+20c – +80c) to safeguard their potency during transportation, storage and distribution to the point of delivery

  20. Operational Def… • Practice on cold chain: Maintaining a network of refrigerators, cold boxes & vaccine carriers for keeping vaccines within the recommended range of temperature (+20c – +80c) to safeguard their potency during transportation, storage and delivery. • Good condition cold chain equipment: The cold chain equipment the are intact and clean to keep vaccines with in the required temperature range (+20c – +80c).

  21. Results and Discussion

  22. Result 1. Profile of the Study Population 1.1. General Characteristics of Health Facilities • Among 116 facilities, 13 (11.2%) were H/Centre and 103(88.8%) were Health Posts. • Ten(8.6%)health facilities were located in urban and 106(91.4%)in rural setting. • Thirty one (26.7%) were located with in 10kms and the remaining 85(73%) located 11kms to 55kms away from the district health offices

  23. 1.1. General Characteristics of H/F Cont.. • Out of 116 facilities, 38(32.8%) facilities had refrigerators, and out of these only 22(57.9%) were functional. (Therefore, more than 94 (67.2%)facilities transported vaccines from where there is functional fridges) • Seven (18.4%) had a functional generators for backup service and • Twelve (31.6%) had a car/motorbike for transportation of vaccines in case of refrigerator/power failure. • Fuel was available for only 4(57.1%) generators, 8(66.7%) car/motorbikes and 9(23.7%) refrigerators.

  24. 1.1. General Characteristics of H/F Cont.. • From 38 health facilities with refrigerators, • 12(31.6%) had trained personnel and 8(21.1%) had spare parts for minor maintenance. • Twenty four(63.2%) facilities permanently assigned personnel to follow up the cold chain during working hours • Only 14(36.8%) assigned personnel during holydays/weekends

  25. Table 1: Infrastructure and Cold Chain Equipment/Resource Availability in the Study Facilities (CORE Group Polio Project Implementation Districts in Amhara, Oromiya and SNNPR, Ethiopia), December 2011 – January 2012

  26. 1.2. Profile of the Health workers • Of 116 providers included in the study, 18 (15. 5%) were Nurses and 98(84.5%) were Health Extension Workers(HEWs). • Among the Nurses, 13were providing immunization services in Health Centers and 5 in urban health posts • All Health Extension Workers were serving in rural health posts. .

  27. 1.2.Profile of the Health workers Cont.. • Thirty(25.9%)providers had served for a period of 2 years or less while 68(58.6%) had worked for more than 2 years in the routine immunization unit . • Out of 73 (62.9%) trained respondents, • 31 (42.5%) trained on Immunization in Practice (IIP) for six days • 17 (23.3%) on Injection Safety for three days • 25 (34.2%) had received other trainings related to minor maintenance of refrigerator.

  28. Result 2. Availability and Adequacy of Vaccines and Logistics • With respect to cold chain equipments, • No vaccines shortage was identified during data collection period • Fifty eight(50%) facilities had adequate ice packs and • One hundred four(89.7%) had vaccine carriers in good condition • Only 65(56%) had foam pad • Of 38 facilities that had refrigerators, 33(86.8%) had functional cold boxes

  29. Result 3: Status of cold chain Important Traits of cold chain • Availability of thermometer • All 22 facilities having functional refrigerators had functional thermometer. • Reading of thermometer • On the day of data collection, out of 22 functional fridges, 16/22 (72.7%) showed temperature reading with in the standard range (+20c – +80c). (In the remaining 6(27.3%) facilities vaccines exposed for the temperature beyond (+20c – +80c), which can be potential cause for loss of vaccine potency) .

  30. Result 3: Status of cold chain cont… • Availability and updating of Temperature Monitoring Chart • Fourteen out of 22(63.35)functional fridges had a temperature monitoring charts • Thirteen (92.9%) updated their recordings twice daily • Vaccine arrangement • Was proper in only 10/22(45.5%) facilities. (Therefore, vaccines in the remaining 12(54.5%) will be at risk of losing their potency )

  31. Result 3: Status of cold chain cont… • Utilization of Foam Pads • For keeping vaccines cool during vaccination sessions were being properly used in only 10/65(15.4%)facilities • Availability of other materials with vaccines • In 9/22(40.9% ) facilities, laboratory reagents, anti- rabies vaccines and maternity medicines were placed with EPI Vaccines; (Two related dangers; failure to maintain vaccine temperature and administering of wrong medicines that have similar container)

  32. Result 3 : Status of cold chain &Important traits of cold chain in study areas, Dec. 2011 – Jan. 2012

  33. Result 4: Assessment of Knowledge of Vaccine Providers’ on Cold Chain Management • Recommended range of temperature and frequency of recording and shake test • Out of 116 health workers questioned about the recommended range of temperature for vaccine storage, 91 (78.4%) responded correctly (failure to know the recommended range of temperature will open the way for outbreak of vaccine preventable diseases and cause wastage of money spent for purchase of vaccines ) • Frequency of temperature recording was correctly described by 67(57.8%)

  34. Result 4: Assessment of Knowledge of Vaccine Providers’ … • Vaccine arrangement in the chest type of fridge Proper compartment for placement of • oral polio vaccine(OPV) • tetanus toxoid(TT) and • diphtheria, pertusis, tetanus, hepatitis B and hemophilus influenza type B (pentavalent) vaccines was correctly described by 83(71.6%), 58(50%) and 30 (25.9%)respondents respectively

  35. Result 4. Assessment of Knowledge cont.. • Vaccines that required shake test and its purpose • Only 15(12.9%) health workers knew the three vaccines that requires a shake test • The purpose for application of the shake test was correctly mentioned by 42(36.2%) health workers • Types of Vaccines most sensitive to heat, extreme cold and light • Were correctly identified by 52(44.8%), 25(21.6%) and 58(50%) respondent respectively.

  36. Result 4: Assessment of knowledge cont.. • Vaccines need conditioned ice packs during transportation • Known by only 15(21.6%) respondents. (Since more than 94 facilities transporting vaccines from other facilities, all of them should at least to know how to pack different vaccines in the same container while transporting) • How to reconstitute vaccines • None of the providers were able to fully answer how to handle the reconstituted vaccines • Only 18(15.5%) answered three out five questions correctly, while the remaining correctly responded to less than three questions

  37. Result 4: Assessment of knowledge cont.. • Vaccines under MDOVP • Seventy three (62.9%) providers new about two vaccines under Multi Dose Open Vials Policy(MDOVP) and • All preconditions necessary to administer MDOVP were mentioned by only 37(31.9%)respondents • At least three preconditions were mentioned by 36(31%) • While 34(29.3%) respondents did not know of either • 54(46.6%) respondents correctly mentioned the length of time required to keep vaccines in the vaccine carrier after outreach session

  38. Result 4: Assessment of knowledge on cold chain management in the study areas in Dec. 2011 – Jan. 2012

  39. Level of knowledge of cold chain management • The level of knowledge of providers on the cold chain management was classified as Not satisfactory and Satisfactory based on mean score which is 21. • Accordingly, 63 out of 116(54%) providers have Satisfactory knowledge . (above the mean score) • And 53(45%) provider have Not satisfactory knowledge. (less or equal to the mean score)

  40. Factors associated with the knowledge of cold chain management • Professional Qualification and Year of Service on EPI have significant association with knowledge on cold chain management. • The result of logistic regression analysis indicated that; 1. The Odds of having satisfactory knowledge on cold chain management among Nurses was about 9 times more likely than Health Extension Workers (Adjusted OR 8.83, 95% CI 1.4 – 19.4). 2. The Odds of having satisfactory knowledge among providers who have more than two years of experience on EPI were about four times more likely than those with less than two years services (Adjusted OR 3.57, 95% CI, 1.02 – 12.4).

  41. Table 2: Factors associated with knowledge of cold chain management in study areas

  42. Discussion • In this assessment, out of 116 health facilities, only 38(32.8%)had refrigerators, of which only 22/38(57) were functional. Health workers from the remaining 94(81%) facilities transported vaccines from health facilities where there were functional refrigerators, which can be a potential cause for cold chain breakage that can adversely affect vaccine potency through exposing for high temperate.

  43. Discussion • Of 16/22() functional refrigerators working with both electricity and kerosene; 7/16(43.8%) reported frequent kerosene shortage. Since electric supply is not regular, availability of reserve kerosene should be prerequisite for maintenance of vaccine potency and sustainability of immunization services delivery.

  44. Discussion • In case of any emergency situation, interruption of power or kerosene supply, generators and vehicles were available in only 7(18.4%) and 12(31.6%)facilities respectively. Frequent cut in power supply can have a direct impact on storage temperature and non availability of standby generator will adversely affect vaccine potency at the vaccination centers.

  45. Discussion • During our survey, trained personnel and spare parts for minor maintenance were available in 12(31.6%) and 6(15.8%) health facilities respectively • As vaccines are biological products that need continuous maintenance within a recommended narrow range of temperature. • In this respect availability of trained personnel and spare parts at all health facility level are mandatory for regular follow-up and timely maintenance

  46. Discussion • One encouraging finding of this study was that all 22(100%) functional refrigerators had thermometer. • However, only 16(72.7%) had reading within the recommended temperature range (+20c – +80c). • Vaccines in the remaining 6(27.3%) refrigerators were exposed to temperature outside the recommended range. This situation could potentially lead to loss of costly vaccines and accidental administration of compromised vaccines.

  47. Discussion • Of 22 functional refrigerators, only 14(63.6%) had a temperature recording chart and among these, 13/14(92.9%) maintained the twice daily recording practice. • WHO has recommended that the temperature range for vaccines should be (+20c – +80c), to be read and recorded twice daily. • This procedure helps for self monitoring to prevent breaking of cold chain that can contribute for primary failure of immunization services.

  48. Discussion • One of the disturbing practice identified in this study was that the arrangement of vaccines in refrigerators was not correct in 12/22(54.5%) health facilities. The success of efforts by countries against vaccine preventable diseases is attributed in part to proper storage and handling of vaccines. By arranging vaccines in the right compartment of different types of refrigerators could prevent vaccines from exposing to the wrong temperature and losing their potency.

  49. Discussion • This study also showed that vaccines were sharing space with laboratory reagents and other medicines in 9(40.9%) fridges Ideally the fridges containing vaccines should not be used to store other drugs in order to prevent two potential dangers; problem of not maintaining the recommended temperature range and wrongly administering drugs that have been packaged in similar color vials as the vaccines vials.

  50. Discussion • Of 116 health workers included in the study, 91 and 15 knew the recommended range of temperature for vaccine storage and vaccines that need shake test respectively. The poor knowledge about correct storage temperature and shake test may be expected to adversely affect the quality of administered vaccines and consequently can give way for outbreaks of vaccine preventable diseases as it is evidenced in many parts of the country.

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