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  3. Thursday, 02 August 2012

Many thanks to Mojtaba Haghgou for sharing this article with the forum.

Vaccine cold chain functional inventory and gap analysis: Looking at all existing cold chain equipment at one go
Ministry of Health and Medical Education, Iran, July 2011

By Dr. Mohsen Zahraei, EPI Manager and Mr. G. Zamani, Vaccine Logistics Manager, Ministry of Health and Medical Education, Iran, Mr. A. Yarparvar, UNICEF Country Office Tehran, Iran, Mr. M. Haghgou, Consultant

Iran delivers children immunization services through an advanced and integrated Primary Health Centre (PHC) system. Forty-six medical universities acting as provincial health authorities implement the health policies set by the Ministry of Health and Medical Education (MOH & ME). With absolutely no foreign assistance, Iran has reached 100% universal child immunization coverage for all vaccines over the last 20 years and this high coverage has been maintained. Polio has been eradicated in Iran and measles is under control.

Since all vaccine cold chain equipment is relatively old and needs to be replaced, in 2010, with financial and technical support from the UNICEF Country Office, the MOH & ME embarked on a project to evaluate the cold chain equipment; make a full functional inventory of all existing equipment; complete a gap analysis; and make a comprehensive plan for renewal of the vaccine cold chain. The findings of this survey will serve as the foundation for the comprehensive plan.

This survey was designed to register all equipment, from vaccine carriers to cold-rooms, back-up generators and vehicles for vaccine transportation at all levels and in all existing and working facilities throughout the country. In order to collect data, two separate questionnaires were prepared, field tested, and staff were trained to use them.

A total of 23,916 facilities at seven levels of PHC service delivery and storage facilities (provincial, district, urban, urban/rural and rural health centres and heath posts and health houses) were visited. Fifty-three items of information on all types of equipment, including capacity and condition of each unit, was collected. The survey also included 18 items of information on logistics required for planning, and staff’s educational level. A total of 269 cold and freezer rooms, 24,784 refrigerators and freezers, 2,948 cold boxes, 20,264 vaccine carries, 60 refrigerated vehicles and 175 back-up generators were registered and detailed information was collected. In addition, the educational background of 413 staff was evaluated.

The collected data were sorted and analysed with a goal-oriented approach. A computer interface was developed for data entry. The collected data from the questionnaires were loaded to the MOH & ME server by staff from all the 46 medical universities at the provincial level.

This survey is unique in its approach, the number of facilities visited and the amount of data collected and computerized. The principal investigators ensured that the methods used for the survey could be replicated elsewhere. Further, the structure of the report aims at providing a guideline for other countries and programmes to use the same approach. Although the results of the survey is for the national level, each medical university (province) or district will be able to access their own data and use them for their own purpose of analysis for provincial-level programming and planning. The collected data will remain on the portal of the MOH & ME and there is a plan to put in place regulatory frameworks for all medical universities (provinces) to update the data on a regular basis. This will provide an updated profile and a real-time inventory of the cold chain for the whole country.

As a by-product of this survey, an estimation of under-one migrant children covered by the PHC system together with the general population covered by the out-reach teams was obtained for each province and has been presented in the report.

The survey results indicated that most of the equipment is old and needs to be replaced. The investigators were impressed with how the equipment was still being effectively used and maintained and the fact that the full-scale programme was running.

The gap analysis compared the available equipment in good condition with what will be required in 2015 when the new vaccines are introduced into the routine immunization programme. The results from the survey suggested that cold storage capacity at the medical university and district levels was not a problem and that there would be adequate cold storage capacity for 2015 at the provincial and district stores except for a few rather less populated and newly established provinces.

However, there is a shortage of refrigerators, cold boxes and vaccine carriers at almost all levels. There is a need for an estimated 2,670 refrigerators, 2,627 cold boxes and 29,592 vaccine carriers in relation to the requirements in 2015.

Lack of a standard specification and purchasing policy for cold chain equipment, which has resulted in the procurement of diverse equipment, is one of the most important issues that needs to be addressed at the national level in order to harmonize the cold chain inventory.

Transportation does not seem to be a problem at present, though it may become an obstacle in 2015 for safe keeping of vaccines if no action is taken. Although there are 175 back-up generators in the system, the problem of automatic start-up devices is one of the issues that need to be considered.

In addition to developing a functional inventory of the vaccine cold chain equipment and identifying the gap, the survey also addressed issues related to:
• staff educational levels
• store building condition
• communication
• climate data

With regard to the conditions of the store building, it was found that 18 (39%) of the medical university (provincial) stores and 226 (62%) of district vaccine stores need to be made earthquake-resistant or they need major repair and renovation.

It was assumed that all facilities at the six top levels have adequate communication systems. However, no accurate data is available about the health houses (the lowest level of PHC service delivery) communication system. The survey shed light on this issue too. It was found that 50% of all health houses have a landline telephone connection.

Collection of data in relation to climate, which will be useful for selection of appropriate cold chain equipment, was also part of this survey and features in the report.

An accurate under-one population data for every district has been collected and used for estimation of the requirements in 2015. The surveys showed that only 1.4% of the health houses have zero under-one children. Whereas, the majority of the health houses (57%) cover a range between 10 and 50 under-one children. The average number covered by health houses is 22 under-one children per year.

The study also looked at the functioning of all health facilities, vaccine distribution methods, total annual number of vaccine shipments and maximum vaccine stock for each of the seven levels separately and the distance between stores and facilities. These are strategic data probably not accurately and comprehensively available, particularly at the national level, before this survey was conducted. Since the data analysis and report writing took relatively a long time and since the data will remain on the MOH & ME portal and should be updated regularly, developing software to generate reports and support the data analysis is envisaged.

The Iranian Ministry of Health and Medical Education is ready to share the full report with other countries and the principal investigators are ready to assist the other countries if they would like to conduct a similar survey.

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