POST 01216E: COLD CHAIN MAINTENANCE

POST 01216E: COLD CHAIN MAINTENANCE Follow-up on POST 01214E 17 January 2008 ---------------------------------------------------------------------------------------- Lora Shimp adds to the cold chain maintenance discussion based on her experience in various countries. The need for accessible, well-trained technicians cannot be stressed enough. She also voices concern about the poor condition of vaccine carriers. A related aspect that needs to be given thought to is how aged, broken down units that cannot be repaired are to be disposed of. *********************************************************** COLD CHAIN MAINTENANCE: PREVENTION IS BETTER THAN CURE Greetings and Happy New Year. I am writing in response to the interesting and thought-provoking contribution by Mogens on cold chain maintenance. At every review or supervisory visit that I have been on in the last two years (e.g. Madagascar, Ghana, DRC, India), some aspect of cold chain maintenance problems has come up. New equipment is being distributed, but older equipment is still in use and often needed as back-up due to delays in provision of new equipment, need for additional stock capacity (permanent and temporary), or occasional problems with new equipment. Overall, the system seems to be working. Cold chain reviews and evaluations are happening. Cold chain equipment needs are being drafted into lists and addressed, with updated equipment getting to the field. When cold chain problems arise, facility staff usually find some sort of temporary solution. The distribution of the equipment varies, however, and is not necessarily prioritized by areas of most need or on a really in-depth analysis of the cold chain inventory realities. For example, why is a piece of equipment not functioning or "en panne" - is it a temporary, fixable problem or an age/major repair problem? The staff monitoring the cold chain often do not have sufficient training on the newer equipment, as noted in Mogens' email, to be able to identify the extent of the problem. Also, inventory or evaluation lists often don't go into why the equipment is not functioning. A few examples from recent field visits to highlight maintenance and repair issues: 1) In Madagascar, they continue to deal with issues of temporary cold chain equipment problems. Surveys found that this has often related to stock-outs of wicks and glass chambers (due to a sole procurement company found only in the capital and therefore the need to centralize spare parts procurement). In 2001, this was affecting over 50% of the cold chain. Now, it's probably about 20% and the ICC (with good assistance from WHO, USAID/SanteNet, UNICEF, and others) has been working to centralize procurement through the health supplier, Salaama, to avoid these stock-outs. It's moving forward but has been a long process, in part because of decentralization to districts (who are now to procure and pay for their own spare parts and fuel. An added potential problem to this is that the recent supply of new refrigerators in Madagascar require a different size mesh, so this may mean the need for 2 separate procurement orders... 2) A specific (but indicative) field observation from a Health Center: A new mixed (electric/kerosene) fridge in a health center in southern Madagascar that I visited during the MCH weeks in late October was running well for 4 months, and then stopped cooling. They have therefore been using the old fridge for over a month. The woman trained on the new fridge maintenance had the manual (which we looked at), but it seems the problem may be a faulty part, which requires a more advanced technician to determine. Due to intermittent electricity, we also couldn't determine if it is a problem related to the burner or with the unit itself. This requires taking the fridge to a location where the electrical component can be tested. The center is only 30 minutes from the regional office, and someone has come out to look at the problem. After the MCH Week, they were going to take the fridge to the regional office to look at it, but this will take another several weeks, minimum, to resolve. There is a person at the regional level who has received very basic training on cold chain maintenance, but he is an interim district immunization manager (they are still identifying the Regional EPI focal point) and not a technician. There are technicians at the national level and I was informed that Madagascar is trying to have regional technicians, but this takes time and money, notably since Madagascar is still in the process of restructuring and reinforcing the Regional capacity. 3) In India, cold chain repair is area-specific and equipment procurement is state-specific. In some places in UP and Jharkhand, they out-source repair to local technicians, with varying degrees of quality and familiarity with the equipment. In other cases, they have technicians assigned to manage the cold chain, but many of these individuals have not received refresher training in 10-15 years, and they are not well-integrated with the health facility team. This results in delays in repair of equipment but also very poor stock management and maintenance, which affects the quality of the equipment. Another concern... In all countries visited, the cardboard vaccine carriers provided with polio funding are in wide use, including for routine immunization outreach. Most are in poor condition. It seems that there has not been much emphasis on replacing or ensuring long-term, more durable vaccine carriers. These cardboard carriers are included in lists, potentially giving the impression that vaccine carrier needs are "met". (Side note: Ice packs are usually available and have not often been noted as a problem. In field visits, most ice packs have been sufficiently frozen.) These are just a few quick observations from the field, which include visits to better and poorer performing districts. Therefore, the cold chain problems are not unique to poorer performing facilities. The way the problem is handled, however, relates to the ability of the facility staff to recognize, report, and address the problem. There are numerous field staff who could certainly provide much more in-depth observations and feedback than what I have written. The questions raised by Mogens about the type of maintenance organization and where to locate technicians is very important. It seems that the problem is often "curative" rather than "preventive"; meaning that support comes primarily when the equipment has already broken down, not to prevent this from happening. In addition to having trained technicians "at the ready" and preferably closer to the field (i.e. regional/provincial, not just national), more training is needed on basic maintenance (e.g. not just daily temperature monitoring but also adherence to a routine cleaning/maintenance plan and clear instructions on what to do when kerosene quality is poor or electricity is intermittent). I am by no means a cold chain expert, but neither are many of the hard working field officers who are doing their best but have to grapple with these issues on a daily basis and need support. Thanks for this discussion and best regards, Lora Shimp Senior Technical Officer JSI / IMMUNIZATIONbasics project All members of the TechNet21 e-Forum are invited to send comments on any posting or to use the forum to raise a new discussion or request technical information in relation to immunization services. 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