After reading Umit's book my interest in what I call the "buffered Cold Chain" BCC, was renewed.In his book I found the history and the description of the obstacles which were overcome very interesting.
By BCC I mean a cold chain which will maintain temperatures between 20 degC and 25 degC . These higher temperatures could be maintained with simple low cost systems. The life of a vaccine will be shortened at these higher temperatures however in many instances the reduced life will be adequate. The time to end point at these temperatures can be determined form the the graphs on pg 183 of Umit's book. At 20 degC the life of a VVM 2 vaccine will be 22 days and the life of a VVM 7 will be considerably longer 89 daysand the life of the less sensitive vaccines will be even longer.
An interesting point is that a 5 degC change in temperature will change the life of all
vaccines by a factor of aproximately two, this can be seen form the graphs on pg 183 of Umit's book. For example if the storage temperature of a VVM 14 vaccine increases from 15 degC to 20 degC it's  life will decrease from about 400 days to 200 days, for a VVM2 vaccine if the storage temperature increases from 20 degC to 25 degC the life of the vaccine will decrease from about 20 days to 10 days.
Storage temperatures in the 20 degC to 25 degC are easily attained by thermal electric cooling.These solid state devices are reliable, low in cost and light weight, unfortunately at lower temperatures
they are very inefficient. However in the 20 degC to 25 degC temperature range they can provide reliable refrigeration.
A thermal electric cooled refrigerator can be purchased for less than $100 and with slight modifications the cooler could be connected directly to a solar module.The installed system cost of SDD thermal electric cooler would be about one fifth the cost of a standard compression driven SDD system. The thermal storage required to maintain adequate temperatures at night will be considerably less than what is required in standard SDD refrigerators because the storage temperature will be close to the night time temperature.
Thermal storage requirements could be further reduced by incorporating "Time Temperature Integration"in the monitoring device. On pg 150 of Umit's book he points out how MKT temperatures can fulfill this function. The MKT temperature is a weighted average which counts higher temperatures more than lower temperatures.Details of how MKT temperature is used to determine the impact of a temperature excursion are detailed in the Science section of Umit's book. If for example at night the temperature climbs to 28 degC,and during the day the cooling system reduces the temperature to 12 degC the MKT temperature may be about 22 degC; with this temperature excursion the life of the vaccine willbe the same as a vaccine which is constantly kept at 22 degC. A small electronic device could be built which would display the MKT temperature and also the loss of life of the stored vaccines. The loss of life could be displayed for vaccines of different sensitivities. the results displayed would be consistent the change of life indicated by VVM's.
The Buffered Cold Chain is another tool to expand the cold chain in a low cost manner.
If there is further interest in this concept, please contact me.   Larry Schlussler Phd
Sun Frost  

Dear TechNet-21 community, Further to the publication of the English and French versions of the Decommissioning and safe disposal of cold chain equipment guidance earlier this year (available here https://bit.ly/2xTLDYa), we are glad to share with you that the Arabic and Russian versions of the document are now available in the TechNet-21 Resource Library. To access these documents, please click on the following links:
1. For the Arabic version:  https://www.technet-21.org/library/explore/cold-chain-equipment/5041-decommissioning-and-safe-disposal-of-cold-chain-equipment-arabic
2. For the Russian version: https://www.technet-21.org/library/explore/cold-chain-equipment/5042-decommissioning-and-safe-disposal-of-cold-chain-equipment-russian On behalf of UNICEF and WHO, I wish you an insightful reading and look forward to interesting and fruitful discussions with the TechNet-21 community! Michelle Seidel, Cold Chain Specialist - Immunization Supply Chain, UNICEF Programme Division (UN City Copenhagen)  

Dear TechNet-21 Colleagues, WHO PQS will be engaging with a selected group of PQS product manufacturers on Tuesday, July 10th to discuss and agree on a path forward for some significant proposed changes to immunization cold chain equipment standards. Although this is a closed event, the PQS Team and TechNet-21 are partnering to bring you exclusive insights from the meeting and I will be guest tweeting from the TechNet-21 Twitter account, sharing highlights and pictures from this first-of-its-kind event. All you have to do is follow the TechNet-21 Twitter account and check it on Tuesday, July 10th. If you don’t already follow TechNet-21 on Twitter (@TechNet21Mod) this is a great opportunity to start doing so! Looking forward to your virtual participation! Best wishes, Denise, on behalf of the PQS Team

Dear viewers We wish to share the attached revised version vaccine storage code in the new model of Ice Lined Refrigerator, supplied recently to the planning units in Karnataka and India. Karnataka is going to practice soon and we hope the whole country may also follow the same as it is practicable. Keeping ice-packs in brick style practically feasible way is also demonstrated.   With best regards Holla n team KVG Medical College

Green Energy Limited has developed an off-grid solar generator with lithium battery storage backpack. It is designed to provide continuous off-grid electricity to refugees, disaster victims, medical clinics, schools and matches domestic electricity requirement. We have been conducting a project in Lebanon since April with the Red Cross, testing the performance of our backpack in various settings.  Attached is our latest off-grid solar backpack with lithium battery storage. To stay connected and update with our Red Cross testing project in Lebanon either contact me directly via email: stephen@greenenergylimited.com or follow us on Twitter https://twitter.com/GreenEnergyCo2  We are also at final stages of developing another off-grid solar backpack, equipped with an internal vaccine refrigerator that will provide continuous refrigeration for vaccines in communities without electricity supply. It will also supply additional electricity for health workers in the field. The vaccine refrigerator will be able to connect to wifi and 4G temperature monitoring and allow remote access to control temperature setting.   

A new PQS freeze protected vaccine carrier has been approved. The incorporation of this new carrier would solve a serious problem but at a considerable cost. PATH estimates that 2 million carriers would have to be replaced. Several years ago we had been working on a freeze protection method which incorporated water as a phase change barrier between the stored vaccines and the ice packs. This appears to be the same freeze protection mechanism incorporated in the PQS approved carrier. The water barrier in our freeze protection method was created by a water pack which would have the same height and width as a .6 liter pack however it would be much thinner, only about 5 mm thick. When the ice packs are loaded the barrier packs would be clipped against the frozen ice packs. In the carrier the barrier would sit between the stored vaccines and the cold ice packs. The barrier packs would be stored at room temperature. As a consequence of not having to replace the carrier this technique would be much less  costly to implement. Using water pack barriers also offers the flexibility of working with different sized carriers. In addition it would reduce the amount of plastic waste produced with replacement. Sun Frost did not go further with the commercialization of this technique because we did not have the funds for implementation at that time. We would be glad to consult with any company interested in implementing this technique. Larry Schlussler Phd Sun Frost

PATH’s Freeze-Safe innovation sets a new benchmark, helping protect vaccine potency, reducing health worker burden, and providing cost savings to health systems Seattle, February 7, 2018—This week, the first commercially available freeze-free vaccine carrier will begin introductory field trials in Nepal. This follows the World Health Organization (WHO) announcement that the Indian-made carrier using PATH’s “Freeze-Safe” reference design passed WHO Performance, Quality, and Safety (PQS) laboratory tests for User Independent Freeze Prevention, which prequalifies it for use in global immunization programs. This is the first low-cost carrier innovation available to address the widespread and long-standing problem of vaccines freezing in the cold chain during the “last mile” of outreach to infants and children.
[Read more]   Media inquiries: Global: Kate Davidson | media@path.org India: Anil Cherukupalli | acherukupalli@path.org

Hi, I am in need of the following items and I am looking for supplier recommendations. Just need a few of each for R&D.   Empty vaccine vials with stoppers Glycol solution for vaccine vials Portable vaccine cooler (used to carry vaccine to remote locations)   Thanks for the help  

All, I am trying to solve the following problem... We have small medical teams that travel to remote locations, to deliver vaccines to patients. Many of the routes are through jungle, mountains, dessert, etc and take several hours or longer to reach to destination. The teams use motorbikes, and walking through rough terrain to get to the destination. During the traveling, there is no way to tell what's going on in the cooler until the team reaches the destination. We've been asked to: Track cooler location in real time Track cooler temperature in real time This looks like a solvable IoT problem. Look forward to getting experiences and insights on this. Thanks

Three years after the freeze-free concept was reported at the September 2014 meeting of the WHO PQS Committee, the current expectation of availability remains ‘sometime next year’ and it appears that no product has passed the pre-qualification (E004/VC02-VP.1) testing yet. The current status of this product was presented at the last Technet Conference by WHO/PQS. During the resulting discussion, I noted five issues that seem to require attention: The outside dimensions and weight of the current prototype products are greater than the carriers used for forty years. We should see comparative data on dimensions, weight of the new and existing carriers because health workers will carry them, often for long distances. Evidence that the increased weight and bulk is operationally feasible should be confirmed by field testing. Freeze-protection in current carrier designs employs a built-in thermal buffer between icepacks and vaccines. The vaccine carrier including the thermal buffer begins the PQS test at +43C when the vaccine load is added at +5C. Evidence was not shared at the Technet meeting that in fact the new products can cool down the test load to below +10C within 8 hours and what is the maximum temperature during cool down? WHO mentioned, in the context of fixed thermostat refrigerators, that replacement of existing equipment by new models will proceed at a ‘natural’ replacement rate under GAVI CCEOP. If this method of replacement is also followed for vaccine carriers that often survive for 10 years, the renewal process will be too slow to avoid a considerable rate of freezing damage. One question raised at Technet has been raised without a satisfactory answer many times in the last 3 years: “Why is the freeze-free carrier the only solution pursued by global stakeholders”. For example, freezers that deliver their frozen icepacks at a few degrees below zero instead of -20C are feasible, but not explored. Phase change materials as a substitute for water/icepacks have been rejected by PQS without clear evidence. The current PQS focus on passive cooling vaccine carriers with icepacks is likely to be overtaken by active-cooled solutions based on adsorption or thermoelectric technology. This solution, in the form of Global Good’s ‘Indigo’ product, gives outreach teams 5 days or more autonomy and streamlines the process of daily short range activities by switching cooling on and off. In spite of these benefits the product has no specification nor pre-qualification test in PQS because it is an active cooler, not passive. The current process for establishing a new product is said to be more than two years. These questions among others reveal a weakness in the way that the global immunization community handles technology changes for immunization services. Innovation and optimization are treated as ‘solutions hunting for a problem’ instead of operational challenges to the development and growth of immunization – that call for new or improved technologies. Your opinions on how WHO/PQS might strengthen and accelerate this process will be, i I am sure, very welcome !

Dear viewers - Please find the following and the attached illustration for a critical review and needful. Background: CCH Mrs Anitha Beth and Asst CCH Mr Mukesh could not believe when the author shared his observations that the “T” series vaccines were found in “Frozen” condition at the session site far off from the ILR point. Temperature record book never showed subzero recording on any day. CCH had to distribute vaccines to ~50 session sites on Thursdays and ~30 session sites on Saturdays. In a hurry, unconditioned icepacks were loaded in one of the vaccine carriers at about 7 AM and reached outreach at about 10 AM. Jerky movement during the excursion hastens the process of freezing. All vaccination service providers are aware that frozen “T” series vaccines lose potency and the precipitated particles act as foreign body and may result in cold sterile abscess. As per the formal training, vaccine vials are to be kept in a Ziploc pouch and placed in the vaccine carrier packed with 4 conditioned ice-packs. In northern states of India, with more than 2Lakh population per planning unit and ~300 outreach sessions per month, often / accidentally unconditioned ice-packs may be placed as in the above instance. Other common / frequent observations were unclean vaccine carrier, ill fitting lid, no strap to keep the lid in-situ, tampered vaccine carrier, vaccine vials without label, VVM in discard stage, wrong diluent or no diluent, only BCG/Measles/MR/JE, no dropper, only OPV, diluent outside the cold chain in the vanity bag, no starting date on vaccine vials of Open Vial Policy [MDVP] and the like. And now: Recently, on 21st April 2017, a senior consultant from New Delhi also being directed by his superiors from an international RI development partner agency visited the dedicated vaccination clinic of our KVG Medical College to address above issues, especially to avoid freezing of vaccines in the vaccine carrier while transporting. In response to this I wish to share the following, practicing in all the 3 Planning Units attached to our college with illustrations. Transparent plastic container has a screw cap, tapering towards the bottom and is icepack height. Holes are made using heated tip of piston of 2mL glass syringe for sustaining uniform temperature both inside and outside the plastic container within the vaccine carrier. However; inspite of training, orientation, re-orientation; passionate Sustained supportive supervision is indispensable, helps in hands on training, maintains perfection of the programme. Anticipated benefit: Apart from ensuring delivery of quality vaccine, this incurs negligible expenditure, aesthetic, easy to operate and can save millions of $ on operational research of designing new generation vaccine carrier. Sharing with the viewers for comments / sharing their experiences in this field.

Vaccine carrier and Cold box selection tool. Dear Cold Chain colleagues, UNICEF SD has developed a tool which makes the process of selecting Vaccine Carriers or Cold Boxes easier. Please follow the below link to the UNICEFCold chain support package and click on the tab 7. Vaccine Carriers and Cold Boxes. Scroll down to find the tool. Any comments you may have regarding this tool would be much appreciated. Regards Andrew McCourt

PATH is pleased to present “Building Next Generation Immunization Supply Chains” a special edition of Vaccine journal which brings together evidence from global experts in 31 articles representing decades of work by country governments, implementing partners, and donors to improve immunization supply chains (iSC). The articles address the impact of iSC on vaccine coverage, current challenges, and successful pilots, promising ideas and innovations, and upstream solutions that can all help mitigate these challenges. Guest editors of the journal include Benjamin Schreiber (UNICEF), Bruce Lee (Johns Hopkins Bloomberg School of Public Health), and Raja Rao (Bill & Melinda Gates Foundation). Compiled in this way for the first time, the evidence presented in the special edition will serve as a ready reference for supply chain practitioners, underscore the importance of iSC performance for all partners in vaccine discovery and delivery, and help elevate performance improvements onto the priority agendas of global, regional, and country level stakeholders. To support the special edition and to tell the story of how strong immunization supply chains help vaccinate more kids and save more lives, PATH developed an accompanying digital feature: Connecting the Dots: How to get vaccines to more kids. The feature is designed with animated illustrations and social media friendly content to help build awareness for this important aspect of immunization programs. We invite you to check it out and share it with your networks using the social media toolkit below. What can you do? Learn More · Visit Connecting the Dots: How to get vaccines to more kids · Read Building Next Generation Immunization Supply Chains Share with your networks · Easy retweet: https://twitter.com/PATHtweets/status/847508916422496256 · Share on Facebook: https://www.facebook.com/PATHglobalhealth/posts/10154185969685059 · Social Media Toolkit: http://pathisc.nptoolkit.org/

Hi All, PATH Senegal Office had proceeded last year a field evaluation of Sure Chill’s long-term passive device for the use of cold storage of vaccines in Senegal and provides important feedback in terms of thermal performance, end-user inputs, and perceptions at the Ministry of Health of the potential impact of the device on vaccine storage and availability in Senegal. Please find the study report by clicking on the following link: http://www.path.org/publications/detail.php?i=2706 For more information, please contact Joanie Robertson: jrobertson@path.org or Abdoulaye Gueye: agueye@path.org PATH, bureau du Senegal a procédé l'année dernière à l'évaluation sur le terrain de l’appareil passif à long terme Sure Chill pour la conservation au froid des vaccins au Sénégal et fournit des commentaires importants en termes de performances thermiques, de contributions des utilisateurs finaux et de perceptions du Ministère de la Santé de l'impact potentiel de l'appareil sur la conservation et la disponibilité des vaccins au Sénégal. Merci de trouver le rapport de l'etude en cliquant sur le lien suivant: http://www.path.org/publications/detail.php?i=2706 Pour de plus amples informations, merci de contacter Joanie Robertson: jrobertson@path.org or Abdoulaye Gueye: agueye@path.org Best regards, Abdoulaye

Does anyone have experience with vaccine passive storage devices in the field? We are piloting the PQS pre-qualified Arktek device in three rural health centers. By design, the device maintains a temperature range between 0°C and 10°C which will not freeze the vaccines so should not pose any risk to the potency of the vaccines. We are seeing some unease from health workers and EPI managers, though, who are concerned that vaccines would be out of the 2°C – 8°C range and at risk of freezing, even though all the evidence shows this type of passive storage device will not freeze vaccines when following proper procedures for conditioning the ice. On the one hand, this reaction from the health workers speaks to the success of training and insistence on good temperature control between 2 and 8°C. On the other hand, this new technology requires changes to standard operating procedures that have not been fully vetted with stakeholders and still require education and updating. Has anyone else had experience with this? Any suggestions on how to approach these types of changes to procedures required for this new technology? I appreciate any thoughts. Wendy

Within the next ten years access will be extended to immunization for the families of approximately 20% of the world’s new-borns who have never seen the health service. Some will be located in remote areas that suffer from lack of infrastructure, hostile topography and extreme temperatures. Reaching these ‘last mile’ communities with routine immunization and other health services will be hard – perhaps as difficult as reaching the 80% coverage that has already been achieved by most countries. At the heart of the supply chain the vaccine carrier must be able to keep vaccines cool for long periods and be compact enough to be carried by 4w-vehicle or by boat or by motorcycle or carried on foot several kilometers. The traditional choice of vaccine carrier, equipped with frozen icepacks places vaccines at risk of freezing, despite efforts to establish ‘pre-conditioning’. At least two alternative solutions are now in development. First, the design of vaccine carriers is being modified to protect vaccines from freezing and these ‘freeze-free’ will be available soon to gradually replace traditional carriers. A second potential solution is to use ‘PCM’-filled icepacks instead of water-filled icepacks in traditional carriers. A table in the attachment below compares the attributes of PCMs in traditional carriers with those of frozen icepacks used in freeze-free carriers. You are welcome to join the discussion on the relative merits and drawbacks of the two alternative solutions! (NOTE: Please see the attachment!)

PATH’s Total Cost of Ownership (TCO) tool for cold chain equipment is now available for download and use. The TCO tool is designed to help countries compare and understand the costs associated with the purchase, installation, and ongoing operation of cold chain equipment. The tool currently covers 82 cold chain equipment devices including all 72 PQS (Performance, Quality and Safety) prequalified devices from the E001 (cold rooms and freezer rooms), E003 (refrigerators and freezers), and the long-term passive devices under E004 (cold box and vaccine carriers) categories. Using local country costs such as labor and energy rates, the TCO tool calculates costs for purchasing and operating cold chain equipment over time through multiple views such as: cost over useful life, cost per liter of storage, and recurring operational costs. Additionally, the tool can incorporate facility segmentation requirements to match equipment and country needs. These features not only allow users to understand cost differentials of one technology versus another (absorption gas refrigerator versus solar direct–drive refrigerator), but they also provide the ability to drill down and compare costs on a model by model basis over a user-defined horizon from 1 to 20 years. The TCO tool can be downloaded from PATH via the following link: https://www.path.org/publications/detail.php?i=2576. After downloading, please check back regularly to ensure you have the latest version/updates. A large thank you to all who have contributed to our efforts developing the tool. The total cost of ownership tool for cold chain equipment was made possible with support from the Bill & Melinda Gates Foundation. Please send any questions or comments to Matt Morio mmorio@path.org.

In African countries during vaccination campaigns or outreach activities in distant places, traditional cold boxes used for vaccine transport may stay cold for a maximum of about four days (if not opened frequently) in ambient temperatures of around 30°C. Health workers some times need to carry frozen ice packs for distribution too. Vaccine carriers used by health workers for campaigns and routine outreach sessions traditionally have a cold life of less than one day. A major challenge facing small, remote health facilities with limited access to equipment maintenance and repair services is to keep vaccines at proper temperatures for much longer periods of time during transport and storage without exposing vaccines to freezing temperatures. If car battery (connected through cigarette lighter socket) operated cold boxes are available, will these help vaccinators during distant outreach activities or during campaigns especially in Africa where teams may have to travel for few days to reach the communities? Currently no WHO pre-qualified car battery operated cold boxes are available. While in market you can find domestic cold boxes with refrigeration and freezing compartments. Imran

Immunization outreach services depend on a protective, affordable and efficient supply chain to benefit rather than obstruct outreach operations. Four potential cold-chain solutions are on offer but each has barriers to be negotiated or removed. The options are: Frozen water packs BUT we should switch to freeze-free vaccine carriers to avoid the risk of freezing: Vaccines certified for use in a ‘Controlled Temperature Chain’: PCM-filled packs used in all existing carriers and boxes prevent freezing BUT pending resolution of cost and other issues by WHO. So, which of the 3 solutions interests you most? Do you know of others? I await your views and look forward to a lively discussion! (See the attachment!)

Veuillez trouver ci-dessous les liens concernant trois documents, liés à la gestion efficace des vaccins, qui sont dès à présent disponibles en français: • COMMENT UTILISER LES CONTENEURS PASSIFS ET LES BRIQUETTES À EFFET ISOTHERME POUR LE TRANSPORT DES VACCINS ET LES OPÉRATIONS EN PÉRIPHÉRIE http://apps.who.int/iris/bitstream/10665/197867/1/WHO_IVB_15.03_fre.pdf • COMMENT CONTRÔLER LA TEMPÉRATURE DANS LA CHAÎNE D’APPROVISIONNEMENT EN VACCINS http://apps.who.int/iris/bitstream/10665/197866/1/WHO_IVB_15.04_fre.pdf • MANIPULATION DES FLACONS DE VACCIN MULTIDOSES ENTAMÉS http://apps.who.int/iris/bitstream/10665/135973/1/WHO_IVB_14.07F_fre.pdf?ua=1

PATH is conducting this survey to learn how vaccine carriers are currently used in the vaccine supply chain and whether they are meeting the needs of the health system. We are interested in global trends as well as examples from individual countries. We welcome any comments or feedback. The survey will take about 15 minutes to complete.

We hope that the results of this survey will help advance future vaccine carrier designs and improve the ability of health workers to meet the needs of their communities and will share the results.

Visit the following link to access the survey:
https://www.surveymonkey.com/s/9D6RGCT