VVM Chart as a Job-Aid for Display

Thank you Alice, we wish to use it in the regular teaching and training programmes as it is very crisp and clear.

Holla n team

Dear viewers, 

We would like to share an additional performance support resource developed for frontline workers. "How to Read a VVM" is a 5-minute video lesson available for download in English, French and Swahili. 

You can find more video lessons on Immunization Academy's website, with topics ranging from vaccine delivery to supply chain. 

Thank you,

Alice Bumgarner
Director, Immunization Academy
[email protected]

Dear viewers

The VVM chart for display is edited on receiving updated information from Dr Umit Kartoglu.

KVG team

Dear Umit

I am responding again because yesterday I read your response and replied in a hurry. Now I read it again and got so much delighted that I thought of communicating this once again, and all your comments are very positive and very much useful. Since my work as of now is a zero budget activity, we started with what is available with us in our dedicated vaccination clinic to share and obtain learning points from techNet viewers with vast field experiences which I got from you. 

I hope the indian RI lovers in the authorized post will also go through this and extend monitoring and supportive supervision to the private sector which they are regularly doing in the public sector. 

Thank you once again

Holla n team 

Dear Dr Umit Kartoglu

I am very much thankful to you for giving so much details on VVM. I will make necessary corrections before printing the Job-Aid for display. I took the photos of what vaccines are available in India and availble with us. OPV/Rotavac have VVM type 2, recently another RVV preparation with VVM30. One type of vaccine can have more than one type of VVMs, e.g. BCG with VVM14 & VVM 30 as mentioned.

Till now I am aware of only 4 types, now I came to know there are 7 types and this is one of the reasons for sharinng to update myself / ourselves.

In india, in the public sector, there is more awareness about VVM on the essential vaccines included in the National Immunzation Schedule (NIS) and in the private sector either there is no VVM or even if VVM is there awareness is not satisfactory. For this reason I made a request with "authorized monitors / supportive superviosrs" to extend their monitoring and SS to the private sector too. Lucky are the beneficiaries of countries where VVM is provided to all (more) vaccines.   

All other details like VVM can reach discard point even when it is in the cold chain etc are also important points for dissemination in the training workshops.

Me and my team thank you personally and as a team

Dr Holla n team

Dear Narayana,

Thank you for sharing what you prepared to offer to health workers as job-aid.

I would like to make the following comments. Hope you find them useful:

HEATmarker® is a trademark of Temptime Corporation, and if mentioned it should be mentioned as HEATmarker®.

VVM is a time and temperature integrator, meaning that the color change is the result of the combination of temperature and time together. In your text, you indicate that “on exposing to heat outside the critically set temperature of 2 to 8^oC, square irreversibly & gradually turns darker...” sounds like as if VVM does not change color if it is kept at 2 to 8^oC. This is not correct, because, even such recommended temperatures have an effect on the VVM. For example, if you keep VVM7 constantly at, say, 5^oC for a year, VVM will lose 35% of its shelf-life at the end of the period. Again, if you keep the same VVM7 constantly at 7^oC (that is still within the recommended temperature range) for a year, at the end of the period it will lose half of its shelf-life. Of course, what is important here is that we have to explain, that the higher the temperature (not necessarily outside the recommended temperature range) the faster the color change.

In the same sentence, you continue, “merging with the outer ring indirectly indicates discard point matching with loss of potency of the vaccine”. Although in theory, this is correct, we should refrain from referring to potency since it may create an understanding of as if VVM is a potency indicator.

You indicate that “based on heat sensitivity of vaccines, 4 types of VVMs are innovated.” There might be only four types of VVM in the Indian market based on the type and manufacturer of the vaccines, but when it comes to VVM types that are available (and WHO prequalified), today there are 7 types of VVMs.

WHO/PQS prequalified VVMs

I would not advocate for the location of VVMs by vaccine type since this could be misleading. Because the location of VVM on the vaccine vial or ampoule depends on its role as a visual cue for the multi-dose vial policy (MDVP). This is clearly explained both in the most recent MDVP document “WHO Policy Statement - Multi-dose vial policy (MDVP): Handling of multi-dose vaccine vials after opening. WHO/IVB/14.07 - retrieved from https://bit.ly/2XC3n6g”, and “Vaccine vial monitor – PQS performance specification, WHO/PQS/E006/IN05.3 -0 retrieved from https://bit.ly/2IZjGlr”. In principle, VVMs are placed either on flip-off caps of a vial or on the neck of an ampoule for vaccines that must be discarded at the end of the session, if opened multi-dose vials of vaccines can be kept up to 28 days then the VVM goes on the label. Why this is important to mention is, because, there could be a liquid vaccine with a VVM on the cap. For example, Cervarix from GSK is a 2-dose liquid presentation, and opened vials of this vaccine should be discarded six hours after opening or at the end of the immunization session, whichever comes first. And to guide the user (with a visual cue) the VVM is affixed on the cap. Other HPV products that are prequalified are from Merck vaccines (Gardasil) and the VVM is on the label. In summary, mentioning the type of vaccine and indicating where the VVM is located is not the best way to explain, best is to mention the visual cue role of the VVM for the MDVP and explain what it means when the VVM is on the label or on the cap of a vial/neck of an ampoule.

Also, I would not make a reference list for vaccines with VVM types. Because, in the future, you may start receiving the same vaccine from another manufacturer and with a different VVM type. Yes, all OPV is with VVM2, but when it comes to other vaccines, the same type of vaccine from different manufacturers may have different VVMs. You will find BCG with both VVM14 and VVM30 produced by different manufacturers. For example, today among 7 WHO prequalified BCG vaccines, Japan BCG and NCIPD products come with VVM7 while all others (from Serum Institute of India, A/J vaccines, GreenSignal Bio Pharma) are with VVM14. Again, today there are 14 IPV products prequalified by the WHO, all products are with VVM7, except the GSK product Poliorix (comes in 1 and 2 doses) is with VVM14. The type of VVM is decided based on the stability characteristics of the vaccine, not by its type.

I liked very much your proposal of “Beneficiaries have right to information; service providers can show the vaccine with useable VVM to the caretakers to gain their confidence for better community participation”. Showing VVMs to caretakers started as a movement in China, championed by the Chinese CDC. In October 2014, Beijing TV local newscast showed the use of the HEATmarker® VVM on the seasonal flu vaccine (http://bit.ly/2ydY26w). In this programme, the head of the Chinese CDC demonstrated the VVM and said that all seasonal flu vaccine for Beijing that year would be coming with VVM attached. He actually asked viewing parents to ask healthcare professionals to show them the VVM. This initiative boosted parents’ confidence with the vaccines and the programme. A similar approach is now being initiated in Kyrgyzstan as part of the priority actions of the HSS2 with Gavi to increase trust in vaccines and immunization services. I would be happy to see and hear that this initiative is spreading to other countries.

Dr Umit Kartoglu

Co-Founder and CEO

Extensio et Progressio

[email protected] and [email protected]