EXPANDED PROGRAMME ON IMMUNIZATION

2. EXPANDED PROGRAMME ON IMMUNIZATION Dr.Qazi Afsar Anwar Assistant Director EPI (Logistics) Khyber Pakhtunkhwa

3. Provincial EPI Cell, KP

4. Cold Chain system of EPI System that ensures 1.Potency 2.Quality 3.Safety of Vaccines by maintaining the correct temperature from Manufacturer to Children/Women

5. What is the cold chain? ♦ Vaccines are sensitive to heat and must be kept cold from the time they are manufactured until they are used. ♦ The equipment and people that keep vaccines cold during their journey are together called the cold chain. ♦ The cold chain is only as strong as its weakest link. We are all part of that chain.

6. How long is the cold chain? ♦ Manufacturer to airport; cold storage at airport ♦ Transport at the correct temperature from airport to storage in central, regional and district stores and in health centers ♦ Transported at the correct temperature to outreach sites ♦ Kept at correct temperature during immunization sessions

7. COLD CHAIN SYSTEM PAKISTAN Vaccine Manufacturer National Vaccine store, NIH-Islamabad Provincial Vaccine store Punjab, Sindh, KPK, Balochistan, AJK and FANA District Vaccine store Tehsil, Bhu, Rhc, FC facilities Vaccinators/EPI service providers Children and Women

8. Cold Chain System Activitiesin Vaccine Facilities 1. Receipt 2. Storage 3. Delivery Receipt Delivery Storage

9. Loading Vaccine Refrigerators ♦ Put vaccines and diluents on the top and middle shelves of the main section ♦ OPV and measles vaccine on the top shelf ♦ BCG, Pentavalent and TT vaccines on the middle shelves ♦ Diluents next to the vaccines with which they were supplied ♦ Arrange the boxes of vaccine in stacks between which the air can move.

10. Choosing a Refrigerator and Freezer • 1. Temperature Zone, the average temperature during the hottest/coldest months should be taken as criteria for the • determination of the zones. • There are three temperature zones for which cold chain refrigerators and freezers will be classified: • Hot zone, 0C to +43C • Temperate zone, 0C to + 32C • Cold zone, -5C to +32C • 2. Vaccine storage capacity, how much vaccines must be stored at 0-+8C or -20C • 3. Ice pack freezing capacity, how many icepacks should be frozen per 24 hours

11. Conti…………….. • 4. Power source, electricity, kerosene or bottled gas. Is supply • Continuous or not • 5. Holdover time, How many hours will the vaccine remain below 10C • Reliability, Repair facilities and spare parts are available • 7. Price, Which refrigerator meets requirements at the lowest cost • 8. Training, Are the users and those in charge of maintenance of equipment properly trained

12. What to do when a vaccine refrigerator is out of order If your vaccine refrigerator stops working, first protect the vaccines and then repair the refrigerator. Protecting the vaccines Move the vaccines to another place until the refrigerator is repaired. If you think that the problem will last only a short time, you may use a cold box or vaccine carrier lined with conditioned ice-packs for temporary storage. For a longer duration, use another refrigerator. Always keep a freezer indicator with the freeze-sensitive vaccines to monitor eventual freezing.

13. Restoring the refrigerator to working order Check the power, gas or kerosene supply. If there is no power, make other arrangements (e.g. store the vaccine in a household refrigerator) until power is restored. If there is no gas or kerosene, get it as soon as possible. If a lack of power, gas or kerosene is not the problem, repair the refrigerator or report to your repair technician or supervisor. Record the breakdown on the daily temperature recording chart. Note: Concerning the routine maintenance and the servicing of refrigerators, WHO technical manuals exist for each kind of refrigerator.

14. All the vaccines should be stored in the basket provided with the refrigerator1.Measles,BCG and OPV in the bottom only2.Freeze-sensitive vaccines (Penta, TT) in the top only.

15. Chest freezer Deep Different Types of Refrigerators/Freezers Solar Powered ILR Mk 074

16. General rules about refrigerators ♦ Opening the refrigerator door raises the temperature. ♦ Before you open the door, plan what you are going to do. ♦ When you open the door, do what you have to do quickly and close the door as soon as possible. ♦ Try not to open the refrigerator door more than three times a day.

17. Storage Principles ♦ Vaccines must not be kept: – In the door compartments of domestic refrigerators – In the salad trays at the bottom of the refrigerator – In contact with the evaporator plate ♦ Must not be confused with other heat sensitive pharmaceuticals ♦ Diluents must be stored at the same temperature at the point of use. This prevents damage to the potency of the vaccine

18. Contingency Plans ♦ Each facility should have a contingency plan for power failures and these must be visible – placed on the fridge ♦ It must be include an alternative storage area/place and it must be adequate

19. Walk-in Type Cold Room

20. Combination Walk-in Type Cold/Freezer Room

21. Cold chain monitoringequipment: thermometers ♦ Health centre staff use dial thermometers, as recommended by WHO to monitor the temperature of refrigerators, cold boxes and cooler boxes. ♦ Max-min thermometers are not recommended as training is required

22. Type of Vaccine Thermometer Dial type Thermometer

23. Type of Vaccine Thermometer Bar type Thermometer (read safety zone as 20 to 80 C & not as 00 to 80)

26. Maintaining cold boxes and vaccine carriers Vaccine carriers and cold boxes must be well dried after their use. If they are left wet with their lids closed, they will become mouldy. Mould may affect the seal of the cold boxes and vaccine carriers. If possible, store cold boxes and vaccine carriers with the lid open, when not being used. Knocks and sunlight can cause cracks in the walls and lids of cold boxes and vaccine carriers. If this happens the vaccines inside will be exposed to heat. If a cold box or vaccine carrier wall has a small crack you may be able to repair it with adhesive tape until you can get an undamaged one.

27. Packing a cooler box 1. Take all the frozen ice packs you need from the freezer and condition them. 2. Put ice packs against each of the four sides of the cold box or vaccine carrier. 3. Take all the vaccines and diluent you need from the main section of the refrigerator and close the door. 4. Put the vaccines and diluent in the middle of the cold box or carrier. Vials may be kept in their boxes or packed without them, depending on how many vials you need.

29. Cold Chain & Vaccine Management Training Cold box Cold box and Vaccine Carriers Vaccine carrier with vaccine vials in foam pad

30. Keeping things cool in the field ♦ Keep the lid tightly on the vaccine carrier in transit. ♦ Keep cold boxes and vaccine carriers in the shade. Do not leave a cold box or vaccine carrier in a vehicle that is standing in the sun. Take it out of the vehicle and put it in the shade.

31. Ice packs ♦ Ice packs are flat, square plastic bottles that can be filled with water and frozen. The required number in a particular cold box or vaccine carrier varies. ♦ Every health centre should have two sets of ice packs, one being frozen while the other is in use. ♦ Condition the ice packs before use

32. Ice packs 0.6 liters 0.4 liters

33. Vaccines sensitive to heatOPV Measles BCG TT Pentavalent Most sensitive Least sensitive

34. Vaccines sensitive to coldPentavalent TT Most sensitive Least sensitive

35. Recommended Storage Temperature for Vaccines

36. What is a vaccine vial monitor? A vaccine vial monitor (VVM) is a label containing a heat-sensitive material which is placed on a vaccine vial to register cumulative heat exposure over time.

37. VVM (Vaccine Vial Monitor)

38. Reading a Vaccine Vial Monitor

39. Cold Chain Monitor (CCM)

40. Cont……..

41. PESHAWAR – PROVINCIAL VACCINE STORE Empty units Non-operational ILRs stockpiled around the store Refrigerated vans for collecting vaccines from NIH

42. Some recommendations at each level after the assessment

43. Provision of Freeze tag for all freeze sensitive vaccines

44. 2.Completing of cold chain monitor at federal, provincial and district level

45. 3. Observe strictly vaccine ordering and stock keeping

46. 4. Designate & train cold chain staff at all levels

47. 5. Observe Multi dose vial policy

48. 6. Perform Ice pack conditioning for freeze sensitive vaccines

49. 7. Adapt an effective vaccine distribution system

50. 8. Monitor stock and expiry dates