Dear members, You may remember an announcement in May 2018 when ThinkWell launched a set of products on the Immunization Economics platform (immunizationeconomics.org/ICAN) on immunization delivery costs. Our launch included findings from a systematic review of delivery costs of immunization programs in low- and middle-income countries, including a unit cost database (Immunization Delivery Cost Catalogue – the IDCC) and summary report with seven pooled immunization delivery unit cost estimates.  We are thrilled to announce that the IDCC has now been expanded to include 30 additional unit costs from nine recently published articles/reports. The unit costs include data from nine countries (Benin, Bhutan, Chad, China, Ethiopia, Haiti, Thailand, Togo and Vietnam). The new data covers health facility, school-based and campaign delivery of oral cholera, meningococcal, HPV and PCV10/13 vaccines. More than 400 unit costs are now available. All updates are live on immunizationeconomics.org/ICAN. Updated IDCC companion products (e.g. summary report, pooled immunization delivery unit cost estimates, etc.) will be released later this year. Want to Learn More? Join upcoming events to learn more about the IDCC!  Email ICAN@ThinkWell.global if you’d like to be kept updated about these events and others moving forward. October 12, 2018, 10:30am GMT+1: Fifth Global Symposium on Health Systems Research (HSR2018), Liverpool, UK: IDCC poster presentation October 30, 2018, 9am EST: Webinar on how to use the IDCC with extensive Q&A Written materials and videos with instructions and guidance on using all tools and products are also available at https://immunizationeconomics.org/ican-idcc-instructions/. Call for User Testers Interested in helping improve the IDCC and other products? ThinkWell is looking for individuals to provide structured feedback in person, by phone or via Skype. If you have 30 minutes available, please contact Michaela Mallow at mmallow@thinkwell.global. About ICAN The immunization delivery cost review and analytics were conducted under the Immunization Costing Action Network (ICAN) project. Led by ThinkWell and John Snow, Inc. (JSI), the Immunization Costing Action Network (ICAN) is a project focused on increasing the visibility, availability, understanding, and use of data on the cost of delivering vaccines. ICAN aims to build country capacity around generation and use of cost information to work towards sustainable and predictable financing for vaccine delivery. The ICAN is supported by a grant from the Bill & Melinda Gates Foundation.

Dear All I am happy to share the information below regarding the UAV for Vaccine Delivery Project in Vanuatu:  Ministry of Health of the Republic of Vanuatu, assessed by UNICEF, invites you to join the pre-tender (kick-off) meeting for MoH project number S1721: "Transportation of Vaccines and Medical Supplies using Unmanned Aircraft Systems (UAS) or Drones", as part of the official issuance of the Tender Process for trialing the use of drones in Vanuatu for vaccine deliveries in 2018. This stage (Phase 2) of the Vanuatu Drone Trial seeks to contract the services of suitable individuals/companies to test their potential, as well as Ministry of Health and Civil Aviation Authority capabilities and protocols, to safely integrate cargo drones in the last-mile delivery of the existing supply chain, negotiate costs, and develop a business model for a longer and wider stage during 2019 (Phase 3), and onward if successful. Pre-Tender (kick-off) meeting: Morning Option: in-person OR virtual Date: Wednesday, 30 May 2018. 8:30 am Vanuatu Local Time (UTC+11) Location: Ministry of Health Malaria Conference Room. Rue Cornwall and Rue d'Artois. Port Vila- Vanuatu  OR join via Skype https://meet.lync.com/unicef-org/cvazquezpaez/9OIMVWKN Evening Option: virtual Date: Wednesday, 30 May 2018. 5:00 pm Vanuatu Local Time (UTC+11) Location: join via Skype https://meet.lync.com/unicef-org/cvazquezpaez/ZB324ULF   Tender documents and project information can be found in : http://unicefstories.org/drones/vanuatu/   Ridwan Gustiana UNICEF Vanuatu rgustiana@unicef.org     

This is the third topic in my six-part Vaccine Supply Chain Futures series, and concerns changes in vaccines and the technology of administration of vaccines. No change in supply chain technologies can impact immunization coverage more than change in the presentation and administration of vaccines themselves. The more compact and thermo-stable vaccines become, the more children can be reached for immunization. As services seek the last 20% of children who have not been reached and as the number of vaccines to be delivered increases steadily, streamlining the process by design is now a high priority. But progress has been slow and many key issues including those now presented in the file attached to this post, are at best only partly addressed. Please reply to this post with your views and I would be grateful if you could answer just four questions in this SurveyMonkey: https://www.surveymonkey.com/r/69L2NZS I will return the analysis to you at the end of next week 22/09/17 and the results will be posted before the TechNet Conference for all five topics. Thank you!

PATH wants to better understand how immunization program managers, procurement officers, and other immunization experts view the tradeoffs between liquid and lyophilized presentations ofrotavirus vaccine for use in different settings. To gather feedback from those most knowledgeable about this topic, we’ve designed a short (15 min) online survey. The results of this survey will inform dialogue with vaccine manufacturers and other stakeholders as we work to advance rotavirus vaccine presentations that will best meet the requirements of immunization programs. https://www.surveymonkey.com/s/liquid-lyo We are especially interested in hearing from immunization program staff at the country level. We hope you will take a minute to share your input as we seek greater clarity on this interesting topic! Best regards, Sarah McGray

Background: Rabies is a zoonotic disease and many vulnerable sections like rag pickers and municipality workers neglect animal bites due to ignorance of their potential deadly outcomes. Stray dogs abound in garbage pits and this population is exposed to their attacks. It should be a mandate for municipalities to help protect their sanitary workforce, especially rag pickers, from deadly infectious diseases such as Rabies, Hepatitis-B, HIV, Tetanus etc. Objectives: Objective of this study was to study methods to provide pre-exposure Rabies vaccination for such highly exposed populations by engaging them and understanding their perception of this disease through a constant dialogue with them. Methods: We started by engaging with the rag pickers to know how best to entice them to get themselves immunized. We then attempted to search literature for the most practical methods likely to succeed in reducing risk of rabies deaths in this population. Results: WHO approved 3 injections of 0.1 ml tissue culture vaccine on days 0, 7 and 21 were tried but were shown to result in many dropouts among rag pickers for repeat injections. We then followed a method where 0.1 ml of rabies vaccine was injected at 4 different anatomical sited in one setting. This proved acceptable and relatively inexpensive. A small number of subjects were studied by determination of neutralizing antibody by RFFIT, which proved immunogenic having anamnestic response on boosters given single IM or at 4 sites ID subsequently, implying that short schedule rabies pre-exposure vaccination can be done in high risk groups and may save lives if applied to the poorest that are highly exposed. the link to paper is http://www.scirp.org/journal/PaperInformation.aspx?PaperID=53354#.VMJYwUeUdG0 http://www.scirp.org/journal/PaperInformation.aspx?PaperID=53354#.VMJYwUeUdG0 Thanks, Omesh Kumar Bharti

The complete announcement is available at http://www.path.org/news/an120416-needlefree-devices.php. Call for needle-free intradermal delivery devices for upcoming clinical trial In collaboration with the Bill & Melinda Gates Foundation, PATH invites letters of interest and applications from technology manufacturers willing to provide eligible needle-free intradermal (ID) delivery devices for use in a clinical trial of reduced-dose inactivated polio vaccine (IPV) scheduled for 2013 in China. Vision Ensuring wide-scale access to IPV is a key goal of polio eradication efforts and post-eradication planning. The Bill & Melinda Gates Foundation plans to support a clinical trial to evaluate the dose-saving potential of IPV when it is delivered intradermally, which could extend vaccine supply and make IPV more affordable for immunization programs in developing countries. Needle-free delivery devices that facilitate safer, easier, and more consistent ID delivery of vaccine could also enable ID delivery of IPV by less-experienced health workers or trained volunteers. Eligibility To be eligible, devices must be needle free with a disposable, autodisabling fluid path and capable of delivering 0.1 ml of IPV intradermally in infants and children. Manually powered devices suitable for use either in a clinic or in a mobile campaign setting are preferred. Multiple devices that meet these requirements may be included in the trial. Final device selections will be made by the Bill & Melinda Gates Foundation. Please also note that the Bill & Melinda Gates Foundation reserves the right to withdraw this request for applications and/or cancel the planned trial at any time. How to apply Letters of interest are requested by April 27, 2012. Full applications and supporting materials are due May 14, 2012. Applications should include: A cover letter with a description of the materials enclosed. Instructions for use for the device. A completed response questionnaire (see Annex 1 [317 KB PDF]). Supporting documentation, where appropriate. Please email the letter of interest and full application to vaccinetech@path.org. Relevant materials can also be mailed to: Emily Griswold PATH PO Box 900922 Seattle, WA 98109 USA For questions and guidance on this opportunity, please contact PATH (primary) at vaccinetech@path.org or Linda Venczel at linda.venczel1@gatesfoundation.org. More information New vaccine tools for polio from PATH (http://sites.path.org/vaccinedevelopment/polio/) Vaccine technologies at PATH (http://www.path.org/our-work/vaccine-delivery.php) http://www.path.org/news/an120416-needlefree-devices.php

A few more of the HCWM presentations that were made at the annual meeting of the Safe Injection Global Network (SIGN), which was held from 30 November to 2 December 2009. Thanks once again to Selma Khamassi for sharing them with the forum. Non-Incineration Medical Waste Treatment Pilot Project at Bagamoyo District Hospital, Tanzania: Ruth Stringer HCWM: Introduction to Vaccination Campaign: Yves ChartierMonitoring Tool “Implementation of National Healthcare Waste Management Plans”: Ute Pieper ##text## ##text## ##text##

The annual meeting of the Safe Injection Global Network (SIGN) was held from 30 November to 2 December 2009. The following are some of the presentations on Healthcare Waste Management. Many thanks to Selma Khamassi for sending these to me to be shared with TechNet21 readers. HCWM--10 Years: Yves Chartier: A comprehensive summary of the last 10 years efforts in M&E, technology transfer, etc.PATH's work in HCWM: Nancy Mueller: Includes the latest efforts in improved safety boxes and needle-free injection technology.Resource Mobilization for Effective Waste Management: Ruma TavorathElectronic Monitoring Tool for HCWM: Nancy Mueller: An online data collection tool that helps monitor national-level progress in HCWM Assessment and formulation of a strategy on HCWM: Ute Pieper: Based on WHO Euro efforts in Azerbaijan, Kyrgyzstan, Tajikistan Ukraine and Uzbekistan ##text## ##text## ##text## ##text## ##text##

Dear Friends, Here is more on intradermal delivery of vaccines. As many as 10 vaccines can be given intradermally to spare costs as well as doses, but unfortunately this is not promoted by vested interests. Please see the link on the WHO website: http://www.who.int/immunization_delivery/systems_policy/Intradermal-delivery-vaccines_report_2009-Sept.pdf Happy Diwali,Regards,Dr. Omesh BhartiM.B.B.S.,D.H.M.,M.A.E.(Epidemiology)Directorate of Health Safety and Regulation, Himachal Pradesh+91-9418120302[email=bhartiomesh@yahoo.com]bhartiomesh@yahoo.com[/email]; [email]bhartiomesh@gmail.com[/email]

Dear Friends, Here is more on intradermal Influenza vaccine: http://www.ncbi.nlm.nih.gov/pubmed/18652550                http://content.nejm.org/cgi/content/full/351/22/2286 The government of India is importing 2.8 million doses of H1N1 vaccine, but it can come down to 0.7-0.8 million doses if they try for the intradermal route for this influenza vaccine. Five times the saving! Is there anyone listening? Regards, Dr. Omesh BhartiM.B.B.S.,D.H.M.,M.A.E.(Epidemiology)Directorate of Health Safety and Regulation, Himachal Pradesh+91-9418120302[email=bhartiomesh@yahoo.com]bhartiomesh@yahoo.com[/email]; [email]bhartiomesh@gmail.com[/email]

Dear Friends, After Virorab, Sanofi-Pasteur has come out with a low-cost Intradermal Influenza vaccine Intanza® / IDflu® vaccine*, see the link below, http://198.73.159.214/sanofi-pasteur2/ImageServlet?imageCode=24890&siteCode=SP_CORP Dr. Omesh BhartiM.B.B.S.,D.H.M.,M.A.E.(Epidemiology)Directorate of Health Safety and Regulation, Himachal Pradesh+91-9418120302[email=bhartiomesh@yahoo.com]bhartiomesh@yahoo.com[/email]; [email]bhartiomesh@gmail.com[/email]

Dear Friends, It is a great pleasure to know that now Virorav has also come out with the intradermal option (attachment). This will be a further boost to the intradermal ARV campaign in India to controll rabies. After Rabipur, Abhyrab and Indirav, this will be the fourth drug offering a low-cost intradermal option in India. Regards, Dr. Omesh BhartiM.B.B.S., D.H.M., M.A.E. (Epidemiology)Directorate of Health Safety and Regulation, Himachal Pradesh+91-9418120302[email=bhartiomesh@yahoo.com]bhartiomesh@yahoo.com[/email]; [email]bhartiomesh@gmail.com[/email]

We would like to share a report on intradermal delivery of vaccines that was commissioned by PATH's Disposable Jet Injector Project and Project Optimize (a collaborative project between WHO and PATH). The report was authored by Julian Hickling and Rebecca Jones from Working in Tandem Ltd. The purpose of the report is three-fold: 1) To summarize the clinical evidence supporting the intradermal route for vaccine administration and the devices being developed for this purpose; 2) to determine whether intradermal delivery broadly holds promise for vaccine applications for low- and middle-income countries in the future; and 3) to begin to prioritize vaccine targets and device strategies that best fit the public health needs in these countries and likely merit further investigation. We hope the document is useful to others and welcome comments from Technet members. All the best, Debbie Kristensen, Group Leader Vaccine Technologies, PATH and Darin Zehrung, Technical Officer, PATH ##text##

POST 01308E: APPLICABILITY OF CDC’S INTRAMUSCULAR INJECTION RECOMMENDATIONS IN DEVELOPING COUNTRIES 20 AUGUST 2008 ******************************************* For most childhood vaccines, intramuscular injection is the preferred route of administration. The vastus lateralis muscle of the thigh is the preferred site for infants up to 12 to 18 months of age, and the deltoid muscle of the shoulder is preferred for children older than 18 months of age. When properly delivered to the intramuscular level, vaccines increase immunogenicity and produce a better immune response than when they are delivered at the subcutaneous or intradermal level. Needle overpenetration of the intramuscular level into the bone or periosteum can cause pain and/or damage to the bone or periosteum, and it can cause the needle to detach from the syringe. REVIEW OF CDC GUIDELINES BY William C. Lippert and Eric J. Wall Use of the Centers for Disease Control and Prevention's recommended 1–1 1/4 inch needles for intramuscular vaccination in the thigh of children 1 year of age would result in 11% (11 of 100) and 39% (34 of 88) overpenetration, respectively, with a minimal risk for underpenetration at 2% (2 of 100). Patients with vaccinations in the shoulder with the Centers for Disease Control and Prevention–recommended 5/8–1 inches needles would experience 11% (16 of 150), 55% (83 of 150), and 61% (92 of 150) overpenetration, respectively. RECOMMENDATIONS • For vaccination in the shoulder, the new recommendations are a 1/2 inch needle (for any girl weighing 70 kg or less and any boy weighing 75 kg or less) • To ensure proper intramuscular injections in the thigh muscle, the study authors therefore recommend a 7/8 inch or longer needle for all children up to age 6 years. Full article available at: Optimal Intramuscular Needle-Penetration Depth http://pediatrics.aappublications.org/cgi/content/abstract/peds.2008-0374v1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&andorexacttitle=and&andorexacttitleabs=and&fulltext=Needle-Length+&andorexactfulltext=phrase&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT&eaf http://www.medscape.com/viewarticle/579120?src=mpnews&spon=34&uac=67363AY THE ISSUES FOR DISCUSSION: [list=1] Are the results generalisable to children in developing countries with higher malnutrition rates and less subcutaneous fat? Will the needles in such settings be required to be shorter due to less subcutaneous fat? Can data from nutritional surveys give an answer or do we need more studies? [/ol] [list=1] The current length of Kojak Selinge used in immunisation programme in India is 1.2/1.0 inches. How can the current recommendation be adapted in the current supplied syringes- for instance- insert 1¾ of the needle? [/ol] Dr RK Sood ([email=drrksood@GMAIL.COM]drrksood@GMAIL.COM[/email]) India Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01298E: NEEDLE-FREE INJECTORS FOLLOW-UP ON POST 01292E 3 AUGUST 2008 ******************************************* PATH is researching the use of disposable-cartridge jet injectors (DCJIs) for the delivery of vaccines in developing-country public-sector immunization programs. DCJIs potentially offer substantial improvements to health care worker safety and waste management. The ultimate goal is to determine the appropriateness and applicability of DCJIs for public-sector use in low-resource settings, and if the results are positive, to advance the technology for potential market introduction. The team’s work focuses on obtaining regulatory approval of selected devices, conducting bridging studies with EPI vaccines, and implementing a pilot introduction study to understand use of the technology in a real setting. Additionally, the project will examine the feasibility of intradermal reduced-dose delivery of selected vaccines of public health importance. Darin Zehrung ([email=dzehrung@path.org]dzehrung@path.org[/email]) & Emily Griswold ([email=egriswold@path.org]egriswold@path.org[/email]) PATH -------- Needle Free Delivery via Disposable-Cartridge Jet Injector (PATH) Needle-free injectors as a sustainable alternative to syringes (MIT International Review: Spring 2008) Preventing contamination between injections with multiple-use nozzle needle-free injectors: a safety trial. (Vaccine, 4 March 2008) Needle-free injection--science fiction or comeback of an almost forgotten drug delivery system? (Med Monatsschr Pharm. August 2007) http://needlefreeinjectors.com/ Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01295E: NEED FOR A FEASIBILITY BASELINE FOR MEDICAL WASTE DISPOSAL METHODS 29 JULY 2008 ******************************************* Vijay Machcha from ITPI stresses the need to introduce the concept of baseline for medical waste disposal technologies just as it is done for CDM projects. ---------- Efficient waste management is crucial to ensuring a safer planet. When it comes to healthcare services, in addition to the solid municipal waste that is produced, there is also the sharps, pathological, infectious, pharmaceutical, biological, and hazardous chemical waste. There are different ways of disposing of this waste like autoclaving, microwaving, open-pit burning, incineration and non-burn technologies. A thorough comparative analysis of the various technologies on the different parameters including environmental impact, financial viability, impact of transport, etc. is yet to be undertaken. The Clean Development Mechanism (CDM) under the Kyoto Protocol follows an approach of identifying the historical/current baseline of a project and compares the same with the new project to ascertain, whether the overall impact of the project on climate is positive or negative. There is need for a similar baseline analysis to assess the impact of newly proposed/adopted medical waste disposal technology. Countries in transition, which do not have the financial resources to adopt sophisticated technology, need to explore what is the most viable alternative technology that can be adopted. The age-old method of open-pit burning for waste treatment and/or mixing up the medical waste with municipal solid waste is totally unacceptable as it fails to achieve proper waste treatment and decontamination. As opposed to this, an efficient and properly managed incinerator may be a better option to effectively manage waste. However, many studies also indicate that incineration is not the best practice for medical waste management, due to the dioxin and furan emissions. Yet, continuation of the baseline condition, i.e. open pit burning, is much worse than incineration as it results in much higher hazardous emissions with direct human exposure. The other advanced technologies, like autoclaving and microwave treatments also end up with considerable quantities of active organic matter, which is later landfilled, and has resultant health and climate impact. In fact, GHG emissions of non-burn technologies are higher than that of incineration due to release of high global warming potential methane into the atmosphere and leaching. In addition, these technologies require additional energy input for their operations, which is a factor that also needs to be taken into account when determining environmental impact. In fact, there are many factors that need to be considered to make an informed decision when it comes to choosing the right technology for healthcare waste disposal. Among them are the consumables used in the waste management system, transport of waste to treatment plant, emission caused by operation of on-site and off-site treatment plants, emissions from external transport of waste and residues, emission from degradation and leaching of residues in landfill. Both emissions and financial costs of these factors need to be considered. In fact, if incinerators are equipped with advanced flue gas cleaning systems, it may be difficult to determine if non-burn treatment or incineration is the environmentally most preferred option. Additionally, the political climate, sensitivity of various environmental media (air, water, land) also impact choice. What is required is a comprehensive baseline that quantifies the various parameters to help countries determine the waste disposal technology that is best suited to their needs. Vijay Kumar Machcha ([email=mvk@itpi.co.in]mvk@itpi.co.in[/email]) IT Power India Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01292E: NEEDLE-FREE/COLD CHAIN-FREE VACCINE DELIVERY 20 JULY 2008 ******************************************* A peep into the future with regard to needle-free vaccine delivery reveals that innumerable innovative technologies are being researched to deliver vaccines. These range from aerosols to nasal sprays to respirable vaccines (remember the ‘primitive ways’ of gaining immunity against smallpox). The significance of the research outcomes is huge in terms of implication for vaccine safety, waste generation, efficacy etc. Research is also on into cold-chain free vaccines. Probably there will come a day when entire populations can be immunized through an aerial spray? ------ Needle Free Vaccination Via Nanoparticle Aerosols Dr. Edwards is leading a multidisciplinary team using materials science technologies combined with infectious disease, device, and toxicology expertise to reformulate tuberculosis and diphtheria vaccines into aerosol sprays that can be inhaled. The team's ultimate objective is to develop a cell-based BCG vaccine for tuberculosis and a protein antigen CRM 197 vaccine for diphtheria in the form of novel porous nanoparticle aggregate (PNAP) aerosols. Measles Aerosol Project In view of the above and the results of several studies on the administration of measles vaccine through the aerosol route, in 2002, WHO, in collaboration with the US Centers for Disease Control and Prevention and the American Red Cross, established the Measles Aerosol Project, with the purpose of conducting the necessary studies to achieve the licensure of a product (device and vaccine) administered through this route. Development of a Targeted Mucosal Vaccine Delivery Technology Dr. Lo's project addresses two needs: the development of vaccine delivery systems that do not require needles and the design of systems that target specific tissues in the body. Using influenza vaccination as a model, Dr. Lo and his team are working to bind vaccine to specially designed molecules that target mucosal tissue. While their study uses influenza vaccine as a focus, investigators expect the technology potentially could be applied to any pathogen that causes disease in mucosal tissue. They envision vaccines will be given either orally or as nasal spray. Needle Free Delivery of Stable, Respirable Powder Vaccine Childhood vaccines that can be inhaled and delivered directly to mucosal surfaces have the potential to offer significant advantages over injection, the most common way vaccines are given today. Not only might they reduce the risk of infection from HIV, hepatitis, and other serious diseases due to unsterilized needles, they may prove more effective against disease. Nanoemulsions as Adjuvants for Nasal Spray Vaccines Dr. Baker's team is developing a new way of preparing vaccines so that they can be given as nasal drops. These nanoemulsion (NE)-based vaccines use non-toxic lipid droplets less than 200 nanometers in diameter that are absorbed through the mucosal surfaces of the nostrils. They can be easily produced using an extrusion process available worldwide and are antimicrobial, eliminating the need for preservatives or refrigeration. The team is performing proof-of-concept, feasibility, and toxicology studies for a nanoemulsion-based vaccine for hepatitis B surface antigen. Bacterial Spores as Vaccine Delivery Systems To maintain stability and viability, most childhood vaccines must be kept cool – both heat and freezing can ruin them. That means they must be refrigerated at the correct temperature throughout transportation, storage, and delivery. This cold chain is difficult and costly to maintain, especially in developing countries. Dr. Sonenshein and his team are working to create childhood vaccines for diphtheria, tetanus, and pertussis (the DTP combination vaccine), and rotavirus-related diarrhea that can withstand a wide range of temperatures without refrigeration by encapsulating them in harmless bacterial spores that are naturally heat-resistant. Thermostable Vaccines with Improved Stability at Non Refrigerated Temperatures Drs. Sarkari and Coeshott and their colleagues are working to identify Pluronic polymer-based formulations that stabilize vaccines from -10°C to 45°C; Their aim is to develop vaccines that are resistant to freezing and form protective matrices at elevated temperatures. Investigators are evaluating formulations based on Pluronic F127 using vaccines for measles and hepatitis B. Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01273E: CONTINUING THE DEBATE ON ENERGY FOR HEALTH: FINANCIAL INSTRUMENTS/SYRINGE MANUFACTURE AND ENERGY USE FOLLOW-UP ON POSTS: POSTS 01265E, 01269E 29 MAY 2008 ******************************************* Rowan Wagner takes the discussion a little further by posing questions about legitimizing energy expenses on health; he also identifies financing options to support energy expenditure on health. Terry Hart brings in project implementation experience and suggests documenting micro-credit and rural energy projects, and identifying financial models that could be extended for health/education services. Anthony Battersby adds a totally new dimension to the entire discussion by sharing facts about syringe manufacture and energy consumption. The attached ppt examines the resource depletion when it comes to production of syringes for immunization and curative purposes, and the carbon footprint of producing syringes. ----------- Dear Terry, Thanks - Though you cannot provide specific examples of resultant policy, this does provide an example that could be used to generate a case study or point of initial documentation for key governmental stakeholders (especially within health) looking at engaging in the strategic national planning process for energy security, especially low-resource countries where infrastructure is limited and require a more blended approach that utilizes new green technology (which often has cost implications). MORE THINGS TO THINK ABOUT IN TERMS OF POLICY Why is policy important? Policy is important because it outlines political commitment which may result in specific resource allocation and more importantly defined legislation. Why is legislation and resulting laws important? Legislating provides the framework that moves a psychological contract into a greater social realm between individuals, communities, society, etc. This legitimizes resource expenditure and provides a foundation of trust that can be utilized in not just public expenditures but also in the development of new investment vehicles that would provide more sustainability in the health sector (provided there is input from the sector). Let’s explore how this could work out using the information Terry Hart so kindly provided. IT Power India (ITPI), the Indian Ministry of Health and various NGO representatives are invited to attend a national forum on energy on the development of the next energy sustainability plan as part of a sector-wide approach in the national poverty reduction plan. After the presentation of the current situation, several medium and long-term benchmarks are agreed upon in terms of increasing access and use of renewable energy by solar and wind. ITPI during the recommendation phase has submitted a project idea, in which it will with local communities establish a solar grid in a district where the end users have agreed in return to sell back the extra energy generated to the state at a rate less than market in return for getting power for lighting, and the local health center(s) gets essential vaccine supply chain equipment. The state then has the right to sell the excess energy at market rates. Assumptions are made for return on investment (ROI) using DAILYS/QALYS, current energy prices, and forecasted need and future prices over time. Using this project the state could do the following in terms of financing this critical service that provides health delivery, reduces environmental impact and provides development impact (access to light in the evenings provides people more opportunity to study or work and clean energy reduces health problems from smoke or burning fuels for light and heat): § Direct budget allocation – which is heavily dependent on taxes § Finance through issuing medium-term/long-term bond § Provide a legal framework (laws) for the investment community that may provide tax breaks or other incentives to issue a financial vehicle such as a private bond, pooled fund, or direct investment to ITPI. The first mechanism is the traditional way most governments use after going through the process of reviewing policy papers and studies. It has several detractions, such as waste in terms of red tape, speed of payments and general public trust. The second mechanism is common in the US at least for public utilities, schools and some health infrastructure, and has proven better in terms of speed and accountability as bonds require ratings (often done through independent agencies) and legal guarantees in terms of minimal repayment and risk. In addition often bond issues can raise more specifically focused capital that cannot be rerouted due to political resource battles within the government. Its primary weakness is low rate of return for investors because of the low risk associated with governmental guarantees. The last can provide significant capital, but comes with a greater need for transparency and reporting as investors will require more accountability in terms of ROI and meeting actual deliverables. Though all three have strengths and weaknesses they still require legal foundations, and because most policy makers are not public health or medical specialists there lies the potential problem of health or education not being considered as critical especially in industry oriented sectors such as energy. Which health has a great stake in, because the needs of not only cold chains, but diagnostic equipment, computers in logistics chains, etc… Rowan ([email=rowanwagner@yahoo.com]rowanwagner@yahoo.com[/email]) Terry Hart responds to Rowan Wagner’s suggestions with regard to funding alternatives for energy projects. Hi Rowan, Many thanks for your innovative thinking. I like your proposed approach and would hope this could be taken up. As a pre-requisite, there is already a substantial amount of experience with numerous rural financing mechanisms, many of which are both sustainable and operating on a commercial basis. These need to be examined, and models and experiences analysed. For example, MFIs (micro finance institutions) through women’s groups, and group lending are turning out to be very successful with NPAs (non-performing assets) less than 1% in many countries. This provides a good framework for revenue collection for rural energy supply, and could include a cess to offset health service costs. Rural energy supply through battery/invertor packs (some with PV) has become a massive rural and expanding market. Consumer credit is being offered and could be packaged to support the rural health sector services. Mini-grids (localised grids) are often successful in many situations, with a host of variants being practised. Low economy versions include distribution of a light bulb each evening for 3-4 hours against a fee of a few rupees; bulbs are recollected at the end of the evening when the genset or power pack is shut down. Other mini-grids operate with consumer metering on a pay as you use basis. We are currently working towards a pay for energy through mobile phones similar to the phone top-up system. These techniques will reduce collection costs and ensure payments. There are multitudes of models to be considered, many of which can either have energy for health services integrated or revenues can be used to support health/educational costs. As you quite rightly mention, there are also other financial instruments that could be considered. Bonds as you mention could be one possibility. Much of this but not all goes hand in hand with policy revisions and legislation. An important part of this can operate from commercial drivers however. These tend to be the most successful and certainly the most sustainable. Yes I would strongly encourage any action which would facilitate a process to bring together appropriate financial instruments, policy and legislation where required. This could be an important stepping-stone to addressing a multitude of problems related to health service delivery. Best regards ([email=tjh@itpi.co.in]tjh@itpi.co.in[/email]) Terry ([email=tjh@itpi.co.in]tjh@itpi.co.in[/email]) ----------- SYRINGE MANUFACTURE AND ENERGY CONSUMPTION Another energy issue is the energy used to make syringes. In a paper presented at SIGN 2007 (a part of which is attached) I highlighted the fact that there are orders of magnitude difference in energy and climate implications between different syringe manufacturers for the same end product. For example if all the world's syringes (16 billion) were made by the most energy efficient manufacturer their manufacture would consume the equivalent of the electricity used by 250,000 houses in a year. Conversely the least efficient manufacturer's syringes would consume the equivalent of 3.25 million houses worth of electricity. A house worth of electricity = 4,300kWh. Best wishes Anthony ([email=FBA@COMPUSERVE.COM%20t]FBA@COMPUSERVE.COM%20t[/email]) Anthony Battersby FBA Health Systems Analysts +44 (0)1373-830322 ----------- Post generated using Mail2Forum (http://www.mail2forum.com) ##text##

POST 01272E: LOW-TECH SOLUTIONS IMPROVE IMMUNIZATION COVERAGE--THE TRACKING BAG STORY 26 MAY 2008 ******************************************* Tasnim Partapuri and his colleagues from IMMUNIZATIONBasics, India share this story about how tracking bags have enabled health workers in some Indian states to ensure better immunization coverage. Simple innovations like these go a long way in making a success of a programme. It is interesting to observe that, when it came to smallpox eradication in India, one of the factors attributed to the programme’s success was the creativity and ingenuity of the field staff. The other factor was ‘level-jumping’, whereby “junior staff frequently leaped over formal hierarchical levels in order to expedite action”! I invite more readers to share their innovations with us. In addition to posting it on the E-forum, we will also upload these stories and experiences on the TechNet website so that we can build up a library of simple efficient innovations that can be adopted by other countries as well. The text has been condensed and minimally edited for use here. ----------- Follow-up of Vaccination Dropouts: Use of Defaulter Tracking Bags in India The potential “reach” of the immunization program in India, as reflected in BCG coverage¾the first in the series of antigens¾is 78.2% (from the 2006 National Family Health Survey – NFHS3). A continuing concern is the gap between this figure and full immunization coverage (measured at 43.5% by NFHS3). With an annual birth cohort of 26 million in India, a large proportion of children remain who could be fully immunized if they were effectively followed up to complete the immunization schedule. A review of the country’s Universal Immunization Program in 2004 also highlighted this, recommending that all health workers be provided with tools and training on how to track every child. Health workers in India are usually supported at session sites by Anganwadi Workers (AWWs) and Accredited Social Health Activists (ASHAs), who mobilize beneficiaries due for immunization on a particular, fixed day. These beneficiaries are identified with the help of the immunization register and the immunization card counterfoils. The immunization card, updated with the child’s vaccination status and a reminder to return on scheduled dates, is given to the caregiver accompanying the child. The health worker retains a counterfoil of the card to estimate the number of beneficiaries and vaccines required for the next session and to track dropouts. Though immunization registers receive some attention from the health worker, the immunization cards and, in particular, the counterfoils, are often totally neglected. It is quite obvious that health workers have not understood their utility. Printed immunization registers (if available) are bulky, and health workers often prefer not to carry them to outreach sites. As an alternative, tallies of administered doses are noted on a scrap of paper, of course, with the intention to copy the data later into the actual register. The health workers also use hand-made registers to write entries by session. Although the name of every beneficiary receiving a vaccine may be noted down, sometimes the data has no relation to entries from previous sessions. This results in numerous errors in the tracking information, and the registers of the health workers and “mobilizers” (AWWs and ASHAs) rarely match. Some mobilizers do not use the list of due beneficiaries and rely on their memory, and waste time and effort to mobilize beneficiaries who may not be due for vaccination that day, while beneficiaries who are scheduled to receive their shots may be missed. When issued to beneficiaries, all the relevant data is often not entered on the immunization cards. Similarly, the counterfoils retained by health workers are either not filled or not correctly stored or filed based on the recommendation of the Universal Immunization Program Review. But these issues are being addressed in an “Immunization Handbook for Health Workers”, developed in 2006 and currently in use throughout India. It includes instructions to health workers on tracking and follow-up of due beneficiaries and dropouts. A cloth tracking bag, composed of fourteen pockets, is a simple tool that has been developed for follow up of beneficiaries. Twelve pockets in the bag indicate the months of the year. Counterfoils are filed into the pocket indicating the month when the next vaccine is due. The thirteenth pocket is used for counterfoils of beneficiaries who have left the area or have died. The fourteenth pocket contains counterfoils of fully immunized children. Before the session, the health worker prepares a list of beneficiaries due on that day, based on the counterfoils in the pocket for that month. This list is then shared with the AWW or ASHA. As children come for vaccination, their cards and counterfoils are updated, and the counterfoil deposited into the relevant pocket based on when the next vaccination is due. At the end of each month, cards and counterfoils remaining behind represent drop-outs to be followed up. When used correctly, these bags in fact reduce the moblizer’s workload. With a precise list of due beneficiaries, they can focus on visiting the fifteen or so families that are due for vaccinations in the next session. Distribution of these bags has varied, with introduction through some small-scale initiatives, such as hand-made tracking bags by AWWs in Bharatpur (through CARE/Rajasthan) and in a model sub-centre in Agra (with UNICEF/Uttar Pradesh support). To ensure scale and uniformity in their use, one bag each was supplied to all health workers Rajasthan (2005). Other states in India have also followed suit. Costing an average of about 4 US dollars each, the bags have been supplied either in the form of a backpack or as a foldable bag so that it is easy to carry around. But use of the bags remains an issue. Implementation has been limited due to several reasons. Health workers conduct sessions in 5-6 different outreach sites every month. With only one tracking bag, they find it difficult to track children in different session sites. Moreover, the bulky size of the bag discourages them from carrying it on session days. Many health workers have also not yet been trained in their use. In response to these problems, states are devising their own solutions. Uttar Pradesh proposes to distribute tracking bags to all health workers with a “Frequently Asked Questions” guide and instructions on their use, developed by IMMUNIZATIONbasics and WHO-NPSP. UNICEF/Jharkhand has supplied the bags in an innovative, smaller accordion-file design. The bags’ reduced size and their supply for every session site ensure greater use. The tracking bag is still a new innovation in India. Roll-out and implementation take time and effort, particularly to change the health workers’ and mobilizers’ behavior and practices. Distribution and use of the bags need to be ensured and monitored as part of immunization program activities. With new and expensive multi-dose vaccines poised for introduction in the immunization schedule, such low-cost, low-tech solutions can help to reduce the large number of children lost to follow-up in India. Tasnim Partapuri ([email=tasnim@immbasics.org]tasnim@immbasics.org[/email]), IMMUNIZATIONbasics, New Delhi, India Inputs from Manisha Nair ([email=riorajasthan@npsuindia.org]riorajasthan@npsuindia.org[/email]), WHO-NPSP, Rajasthan, Manish Jain ([email=manish@immbasics.org]manish@immbasics.org[/email]), IMMUNIZATIONbasics, Uttar Pradesh, Sumant Mishra ([email=sumant@immbasics.org]sumant@immbasics.org[/email]), IMMUNIZATIONbasics, Jharkhand (Implementation in other states has been undertaken with support from UNICEF and PATH.) Various models of the tracking bags. Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01182E : RETRACTABLE SYRINGE Follow-up on Posts 01166E and 01171E 5 November 2007 ____________________________________ In response to Vijay Kiran’ contribution, Prabir Chatterjee from India provides the following information. On the same site a would-be interesting link "Disposing Immunization Waste in India" is unavailable because of an error in the URL NOTE : We ask all of you to sign your contributions and identify yourself with your full name, and if you have, your affiliation. Those who don’t and do not respond to our message to this effect will not be posted on the forum. Thank you The moderator ____________________________________ There is a site which deals with injection waste disposal (immunization waste specifically). It is a useful site with downloadable documents on a Measles Campaign in the Philippines in which no injection waste was burned. Alternatives like autoclaving, microwaving and deep burying were costed. Prabir Chatterjee ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [email=LISTSERV@listes.ulaval.ca]LISTSERV@listes.ulaval.ca[/email] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________

POST 01176E : PIS/PQS 24 October 2007 ____________________________________ Dear all, WHO PQS secretariat is happy to announce official release of the PQS E10 "safety box for the disposal of used sharps" product specifications and verification protocol which were approved by the PQS steering group on 28 September 2007. The new product specifications and verification protocol as well as the guidelines for manufacturers of waste management equipment are available online. With the approval of PQS E10 safety box performance specifications and verification protocol on 28 September 2007, all safety boxes listed in the PIS 2000 edition are now subjected to re-evaluation that has to follow new PQS procedures. The deadline for submission of product dossier for prequalification for safety boxes listed in the PIS is set as 30 April 2008. The safety box manufacturers having products listed in PIS should obtain the PQS prequalification status to enter the PQS data base for safety boxes. Items that are not prequalified by this date will be delisted and will not be further recommended for purchase by UN procurement agencies. PQS secretariat is still working on the finalization of specifications and verification protocols for needle removers. Once these are finalized and announced, the PIS E10 section will be shut down following the deadline that will be announced later on. PQS secretariat is looking forward to receive submission of product dossiers as described in the manufacturer's guide for PQS prequalification. We would like to thank all organizations, institutions, manufacturers and individuals who contributed to the development of new safety box product specifications and verification protocol. PQS Secretariat will keep TechNet21 readers informed of further developments. Cheers, Dr. Umit KARTOGLU Scientist PQS Secretariat ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [email=LISTSERV@listes.ulaval.ca]LISTSERV@listes.ulaval.ca[/email] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________

POST 01171E : RETRACTABLE SYRINGE Follow-up on Post 01166E 14 October 2007 ____________________________________ [log in to unmask]">Vijay Kiran from India contributes the following comments raising again an important issue of disposal. We have discussed sharps disposal many times before, as recently as June and July 2007 (Posts 01111E and 01121E). John Lloyd had said that "industrial kilns achieve higher temperatures and have less emissions than WDUs, so surely this is a better option if transport costs allow it". My requests for cost data after the last posting remained unanswered. Would these kilns, very numerous in India, provide the solution? And what is being done in India about the majority of syringes used in curative services, to respect the Pollution Control law? Would recycling or melting to make building blocks be a viable option? ____________________________________ Thanks to Carib for posting this. Addition of AD syringe to the armamentorium of injections was a breakthrough since it reduced many programmatic errors of AEFI. But the safe disposal of used syringes is a major concern in view of the stringent Pollution Control law in India. Immunization injections are just 5% of the total injection load, and in numbers amount to 10 injections per each child for a birth cohort of 26 millions. Since burning or burying are not permitted and the steps involved in the disposal process till district level are cumbersome - like cutting the used syringe from the hub using a hub cutter, placing the infected and non infectious waste in various colored bags, disinfecting the same before final disposal in a pit - the entire gamut of injection safety has become a big question mark. The non / mal functioning of hub cutters, timely availability of the disinfectants and various colored bags and the improper training on the use of sharps pit specially in outreach areas up to the block level are of major concern. With this scenario, the addition of the retractable syringes seems to reduce 50% of the problems in injection safety by cutting down the needle stick injuries and access of unsafe injections to the community. Keeping the bulk of injections and the regulations of the Pollution control board in Indian context an implementable solution for final / terminal disposal would be most welcome. Dr. [log in to unmask]">Vijay Kiran Country representative IMMUNIZATIONbasics, India ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________

POST 01166E : RETRACTABLE SYRINGE 3 October 2007 ________________________________ Carib Nelson from PATH is sending you the summary of the following report "Evaluation of a Retractable Syringe in South Africa". As said in his message, the full report is available upon request. NOTE : The "posting" sub-page of our website will be soon edited. May’s postings will be deleted. All those who wish to keep the list of postings in a Word document, please copy it now. It can be copied with retaining of format and active links. You could thus keep your own archives in this format if you wish so. We remind you that Technet archives accessible through the website are searchable, with a quite effective search engine. ________________________________ Here is a summary of an evaluation of a retractable syringe being used in curative and immunization settings in KwaZulu Natal province, South Africa. Users reported a decrease in needle stick injury and that they felt safer when using the retractable syringe. They were also more willing to treat HIV positive patients when using the syringe. In addition to safety, health workers reported time savings and reduced medical waste volume as advantages. Supervisors felt the retractable syringe improved job satisfaction. A cost analysis found use of the retractable syringe to be cost saving. A sensitivity analysis was conducted to show the cost impact of different levels of needlestick, syringe reuse, and syringe pricing. For additional information, or a copy of the complete report and cost analysis, contact Sarah McGray. Carib Nelson Team Leader, Technology Solutions PATH ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [email=LISTSERV@listes.ulaval.ca]LISTSERV@listes.ulaval.ca[/email] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________

POST 01162E : NEEDLE REMOVER ASSESSMENT 26 September 2007 _______________________________________ It is Guyana’s turn to publish a needle removers’ assessment (865K). It was sent by Nicole Dupré of Initiatives Inc., and forwarded with very positive comments by James Cheyne and Carib Nelson both from PATH.. _______________________________________ I think this may be the breakthrough we have all been seeking for all these years to get needle cutters more widely accepted... Cheers. James ------------------ This is a fantastic report from the PEPFAR (1) project in Guyana on needle removers. Very comprehensive, realistic and supportive. Big congrats to Jessica for major contribution to this effort. Carib Nelson PATH (1) President’s Emergency Fund for HIV/AIDS Relief ----------------- Hello, Initiatives Inc. has produced a Needle Remover Acceptability Assessment Report as part of the USAID-funded Guyana Safer Injection Project (GSIP). It was released this month. Please contact me if you would like a copy or the report or would like additional information about GSIP. Best regards, Nicole Dupre Initiatives Inc. Boston MA 02116 USA -------------- The Guyana Safer Injection Project (GSIP) is working to assist the Ministry of Health to find effective, safe and affordable options for final disposal of needles. To provide a mechanism for safe needle disposal, GSIP piloted a needle removal device and sharps barrel at health posts, health centers and small hospitals in regions six, ten and seven. As GSIP prepares to expand to other regions, a review of the efficacy of needle removal devices and sharps barrels is required. This assessment was designed to gather information on the use, acceptability and relative cost of needle removers and sharps barrels in order to provide the Ministry of Health with evidence to help it make informed plans and policies with regard to needle removal devices. ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [email=LISTSERV@listes.ulaval.ca]LISTSERV@listes.ulaval.ca[/email] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________

POST 01142E : PQS DOCUMENTS : DRAFTS FOR COMMENTS 16 August 2007 _____________________________ Dear all, Final drafts of the PQS E10 category performance_ specifications and verification_protocol for safety box for the disposal of used sharps are now available. We would appreciate your comments to finalize the documents. Please provide your comments either in table format or in track changes mode in Word. Please send your comments to pqsinfo with copy to Mr. Andrew_Garnett not later than 10 September 2007 EOB. Mr. Andrew Garnett will be coordinating the work. General_ information on the PQS project can be found on-line. Looking forward to receiving your comments. Thanks and cheers, UMIT Dr. Ümit_ Kartoglu PQS Secretariat ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [email=LISTSERV@listes.ulaval.ca]LISTSERV@listes.ulaval.ca[/email] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ___________________________________________________________________________

POST 01108E : NEEDLE REMOVER EVALUATION 19 June 2007 _____________________________________ NOTE : Adjustments, to be expected, have been made to the Expert database, to solve the few reported problems, especially those concerned with updating one's own data. Some modifications to the design have also been made. We hope that this database will now be fully operational. We thank all those who recently registered and invite potential consultants who haven't done so yet. The message below comes from [log in to unmask]">Huong[log in to unmask]"> Vu, from PATH/ Vietnam, who presents a needle-remover evaluation report. _____________________________________ PATH announces the publication of "Evaluation of a Needle Remover Demonstration Project : A Study from Huong Khe District, Ha Tinh Province, Vietnam." This report ( download) provides background, methodology, results, discussion, and references associated with an evaluation of the project. PATH and National Expanded Program for Immunization, the Vietnam Ministry of Health implemented a six-month demonstration project in Huong Khe District, Ha Tinh Province, Vietnam, to assess the acceptability, performance, and impact on waste disposal of a manual needle remover introduced at commune health centers (CHCs). The evaluation identified opportunities for significant improvement in the management of medical waste at CHCs. Needle removers were found to be a technically appropriate and feasible solution for CHCs, accepted by most health workers and managers, and able to address problems of health care waste disposal in rural areas. Based on the results of this demonstration project, the evaluation team recommended broader introduction of needle removers in CHCs located in rural and mountainous regions of Vietnam. Training and maintenance are critical issues for ensuring successful introduction of needle removers. Should they be introduced more broadly, it would be important to strengthen supervision at the CHCs. Before any device can be introduced more broadly, an evaluation must be conducted to ensure that it is compatible with the types of syringes being used in Vietnam. Safety boxes continue to be an important tool for managing sharps waste in Vietnam. However, unreliable supplies (safety boxes are only supplied enough for immunization injections) and lack of final disposal options present challenges for use. Since this study was completed, needle removers have recently been included in draft health care waste management guidelines developed by the Ministry of Health as an option for sharps waste handling in CHCs in Vietnam. For more information about this evaluation conducted in Vietnam, contact [log in to unmask]">Huong[log in to unmask]"> Vu. For more information on needle removers, visit the Needle Remover Resource page published by PATH. This web page is intended to serve as a resource for countries and programs considering the introduction of needle removers. Visit the page Huong Vu, MD, PhD Senior Program Team Leader PATH Hanoi, Vietnam ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ ======================================================================== Date: Thu, 21 Jun 2007 22:59:49 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01109E : SOLAR REFRIGERATOR MIME-version: 1.0 Content-type: text/html; charset=iso-8859-1 Content-transfer-encoding: quoted-printable TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01109E : SOLAR REFRIGERATOR Follow-up on Posts 01019E, 01027E, 01032E, 01037E, 01045E, 01095E and 01102E 21 June 2007 _____________________________________ This posting contains two contributions. The first comes from [log in to unmask]">S=F8ren [log in to unmask]">Spanner from UNICEF/India. The second is from [log in to unmask]">Gregory [log in to unmask]">Kiluva from UNICEF Supply Division _____________________________________ All the Solar Powered Refrigerators, listed in the PIS are working perfectly well. Provided that: The system is correctly sized. Installation is done as per manufactures recommendations Maintenance is done as per manufactures recommendations. Proper training of users. As for the size, if you need 30l buy 30l, if you need 50l buy 50l. A bigger SPR is more expensive than a small, like a house, car or whatsoever. As for Jharkhand, I could not disagree more see the reasons above. Solar panels might be stolen, so might generators. Many of the generators I have seen, in the same area are idle because of lack of fuel. I would question the cost effectiveness of the generator solution. Soren Spanner Project Officer Cold Chain Health Section, UNICEF, India Country Office, New Delhi -------------------------- Dear All, I have read the two contributions on this post and would like first to respond to Lydie. The three numbers you refer to in the Supply Catalogue refer to

POST 01102E : EVALUATION OF SYRINGE MELTING 9 June 2007 _____________________________________ PATH conducted a field evaluation of 3 prototype syringe melters in Indonesia. These low-cost approaches to syringe melting used local fuel, such as wood, coconut husks, or stoves, as heat sources. All three were effective in reducing the syringes into a small volume of plastic. Areas requiring design modifications were identified for all three. In general there were difficulties with using the same container for the syringe collection box and the melting pot -- as the containers got sooty from repeated melting they became too dirty for use as safety boxes at the injection station. We also found some issues with the smoke and fumes generated by the melting process. It was not clear whether the smoke and fumes from burning the fuel to melt the syringes was any better than just burning the syringes. Overall we found these simple melter approaches might be useful in settings where better control over on-site disposal is needed, but further design work is needed to overcome several problems. Read the full report Carib [log in to unmask]">Carib [log in to unmask]">Nelson Team Leader, Technology Solutions PATH ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ ======================================================================== Date: Mon, 11 Jun 2007 22:51:56 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01104E : IMPROVED MENINGITIS VACCINE MIME-version: 1.0 Content-type: text/html; charset=iso-8859-1 Content-transfer-encoding: quoted-printable TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01104E : IMPROVED MENINGITIS VACCINE 11 June 2007 _____________________________________ Improved Meningitis Vaccine for Africa Could Signal Eventual End to Deadly Scourge. Successful Vaccine Trial Promises Long-Term, Low-Cost Protection From Epidemics in Africa. Indeed t he Meningitis Vaccine Project (MVP) today (8 June) released new data on the performance of a meningitis vaccine in West African children, suggesting that the new vaccine=ADexpected to sell initially for 40 US cents a dose=ADwill be much more effective in protecting African children and their communities than any vaccine currently on the market in the region. Read the full Press Release Visit also the Meningitis Vaccine Project site ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coop=E9ration internationale en sant=E9 et d=E9veloppement, Qu=E9bec, Canada (http://www.ccisd.org ______________________________________________________________________________ ======================================================================== Date: Wed, 13 Jun 2007 12:26:49 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01105E : NEW EXPERT DATABASE MIME-version: 1.0 Content-type: text/html; charset=us-ascii Content-transfer-encoding: 7BIT TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01105E : NEW EXPERT DATABASE 13 June 2007 _____________________________________ It is a pleasure to announce that a new database of experts has been developed and published on the homepage of our site to replace the previous one. This new base is interactive and data will be stored on the site itself. They can be modified or deleted by the user. The list of Areas of expertise has been redesigned, and areas grouped by themes (sometimes arbitrary). Please read the following carefully, it is not so complicated. a) To register : Click on the link at the bottom of the homepage, as before, and submit the form once completed. A confirmation message will appear on your screen. Make sure that all compulsory fields are completed and that the maximum number of seven areas of expertise is not exceeded. b) To modify or delete your inscription : Access the form in the same way as in a), and at the bottom you will find the buttons necessary to these operations. Please first fill the two compulsory fields (Surname/name, and @ddress to identify your inscription) and click on the desired button. To ensure that you are the concerned person (one needs to mistrust evil-minded people that unfortunately exist), the operation will not be done directly. A confirmation message will be sent to you, that include a link. By clicking on this link, you will receive the data relevant to your inscription, that you can modify to submit again. In case of a deletion, data will be deleted by clicking on the link in the confirmation message. Important note : Links in the confirmation messages are HTML executables, and not ordinary links to webpages (URL). For these to be functional, you have to make sure that this function is active in the mail software or browser that you use. These configuration options are normally found in "Tools", then"Options" and finally "Security". If your operating system is Windows Vista, you have to make sure also that the anti-fishing option is desactivated. It is found as well in the security options of your browser. If nothing works, try the "control-click" on the link. c) For those already registered to the previous database : Your data have been transferred to the new database. However fields of expertise have been modified, and two questions have been added. Thus you are requested to update your entry as soon as possible. 1- Access the form as in b). 2- After responding to the confirmation message, your data will appear on the screen. Verify that they are correct. For fields of expertise, if the name is the same in both the old and new form, the box should appear already ticked. If the word is different then it will appear spelled in the box "Other". Delete the content of that box (leaving of course those real "other" unlisted fields of expertise), and tick appropriate boxes in the list. Make sure that you do not exceed a total of seven fields and answer the two new questions. To make a search in the database : The Expert Database is not open to the public for search. If you are looking for consultants, or if you are from a partner organization, TechNet21 Secretariat will be pleased to share with you the link for a search. You are thus invited to communicate with [log in to unmask]">Diana Chang Blanc -------------------------- Keep this message for later use. We invite you to register. If you experience any problem with using the database, or you have any question, do not hesitate to contact the [log in to unmask]">moderator. Your comments and suggestions are most welcome. The Moderator ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ ======================================================================== Date: Fri, 15 Jun 2007 19:20:51 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01106E : VVM ANNIVERSARY MIME-version: 1.0 Content-type: text/html; charset=iso-8859-1 Content-transfer-encoding: 7BIT TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01106E : VVM ANNIVERSARY Follow-up on Post 01101E 15 June 2007 _____________________________________ This is a really excellent posting, full of interesting stories, interviews and policy statements. Congratulations to everyone who labored so hard over so long a period. The interviews went into great length about having this excellent tool (VVMs) matched to the stability of the vaccines to reduce reliance on the cold chain and to expand possibilities for vaccination in hard-to-reach situations. But one concern that I had was the absence of discussion concerning the safety of relying on VVMs to remove each type of vaccine from the cold chain - for example, reconstituted measles vaccine. Indeed, the policy statement's final recommendation confused me: it permits use of vaccines (without distinguishing between some freeze-dried preparations such as measles vaccine from other vaccines) "beyond the cold chain where warranted for routine immunization activities." "Where warranted" is also not explained. The policy statement then goes on to also permit use of all vaccines on a "limited basis" (without explaining what that means) or under "special circumstances" such as NIDs, hard to reach areas, home vaccination, cool seasons, during storage and transport of certain specified vaccines at risk of damage from freezing. Many of these "special circumstances," such as periodic intensifications of routine immunization, are being increasingly relied on in many countries. On the basis of this policy, does measles vaccine no longer need to be carried to the field with icepacks during routine outreach or six-monthly child health days? As long as the expiration date and discard point have not been reached and irrespective of season, can health facilities without refrigerators now store measles vaccine for routine immunization at ambient temperature, reconstituting and using it over 4-6 hours without keeping it cold? How is the reconstituted vaccine to be kept cold, so that bacteria accidentally introduced during unsterile reconstitution or unsterile removal of doses do not multiply at ambient temperature and possibly cause life-threatening adverse reactions? For such a policy to be implemented with safety and without compromising vaccine effectiveness, very clear operational guidelines will be needed. Transmitting these guidelines to health workers will not be an easy task. I remain concerned by the broad scope of a policy recommendation covering all vaccines without distinction. I hope my questions and concerns above can be addressed. Again, congratulations to all on the 10th anniversary of the introduction of VVMs. I know how difficult a struggle it has been. Robert [log in to unmask]">Robert [log in to unmask]">Steinglass Technical Director IMMUNIZATIONbasics ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ ======================================================================== Date: Sun, 17 Jun 2007 23:26:14 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01107E : ORAL POLIO VACCINE COLOUR MIME-version: 1.0 Content-type: text/html; charset=us-ascii Content-Transfer-Encoding: quoted-printable TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01107E : ORAL POLIO VACCINE COLOUR Follow-up on Post 01050E, 01058E and 01100E (An archive error occurred in this last posting and only attachments were retained in the archives) 17 June 2007 _____________________________________ The first message is from [log in to unmask]">Anil [log in to unmask]">Varshney from India. He rightly points to reluctance from health workers to use OPV that doesn=92= t look normal. This is followed by contributions from [log in to unmask]">Hans [log in to unmask]">Everts and [log in to unmask]">Jacqueline Fournier-[log in to unmask]">Caruana, both fr= om WHO/ HQ providing answers to Salah Haithami. I have the feeling that this leaves some unanswered questions, at least in my mind. As nobody asked these questions, I will do myself in a comment at the end of this posting. ______________________________________ Hello all, It is pertinent to note that no health worker will administer OPV with changed color irrespective of ph or potency. Change of color denotes degradation of any of the compounds in the OPV by heat or long time (expired OPV)? Regards , Dr Anil Varshney Consultant ------------------- The explanatory note was not meant to suggest that people actually estimate the PH in the field, but that the pH variation leading to a change in the OPV colour from yellow to reddish does not affect the efficacy of the vaccine. The note meant to give some technical background for managers. 1) all OPV supplied by UNICEF comes from pre-qualified manufacturers 2) all batches are seperately tested for approval by the NRA, including the ones with vials with colour change 3) due to a change of PH there can be colour variations between vials, but this is a known phenomenon and does not affect the potency of the vaccine 4) because there is no correlation between the colour and the potency, it would lead to utter confusion and erroneous conclusions if health workers would start judging OPV quality on basis of colour. Hans Everts -------------------- I can understand the reluctance from health workers and parents in giving such yellow OPV while the usual colour is pink. At the question raised by Dr Salah, "Can we estimate the PH from just seeing the colour?", it is easy to answer "yes, we can" since the rationale of adding phenol red is to know the pH at a glance. It's very risky to advise any country to reject yellow OPV, even when only few vials are concerned, as the wastage would increase and we know that the vaccine is still potent. In conclusion, I believe we need to strictly stick with our previous position confirming that the pH variation leading to a change in the OPV colour from yellow to reddish does not affect the efficacy of the vaccine. Thanks, Jackie Jacqueline Fournier-Caruana, WHO/Geneva ------------------------ All living organisms require a certain range of pH to live and grow, usually around the neutral point, the polio virus being no exception. Referring to posting 01058E, we learnt that this range is 6.5 to 7.2. Growing polioviruses obviously calls for pH control and phenol red is used as an indicator, sometimes further added in the formulation. We all agree, phenol red is a pH indicator so it can be assessed at a glance but I am sure that Jackie did not mean that it can be done with any accuracy or reliability. As Hans said, it is not meant to be done by anyone in the field. Thus I have two questions of a different order. The vaccine production industry appears to still be using phenol red. Is it really the case? Because I just find it difficult to believe that it relies on such an indicator for a large scale production in 2007. If the vaccine, given all other conditions met, is to remain perfectly potent whatever its pH and color, and should be used, then what is the purpose of sometimes adding some more red phenol? Is it only cosmetic so that vaccines leave the plant all looking identical? I don=92t question that the vaccine is still potent, given such a large security margin in terms of immunogenic dose. I just wonder what is the significance of something that appears to be operationally irrelevant in the field. The moderator ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coop=E9ration internationale en sant=E9 et d=E9veloppement, Qu=E9bec, Canada (http://www.ccisd.org ______________________________________________________________________________ ======================================================================== Date: Tue, 19 Jun 2007 21:11:32 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01108E : NEEDLE REMOVER EVALUATION MIME-version: 1.0 Content-type: text/html; charset=us-ascii Content-transfer-encoding: 7BIT TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01108E : NEEDLE REMOVER EVALUATION 19 June 2007 _____________________________________ NOTE : Adjustments, to be expected, have been made to the Expert database, to solve the few reported problems, especially those concerned with updating one's own data. Some modifications to the design have also been made. We hope that this database will now be fully operational. We thank all those who recently registered and invite potential consultants who haven't done so yet. The message below comes from [log in to unmask]">Huong[log in to unmask]"> Vu, from PATH/ Vietnam, who presents a needle-remover evaluation report. _____________________________________ PATH announces the publication of "Evaluation of a Needle Remover Demonstration Project : A Study from Huong Khe District, Ha Tinh Province, Vietnam." This report ( download) provides background, methodology, results, discussion, and references associated with an evaluation of the project. PATH and National Expanded Program for Immunization, the Vietnam Ministry of Health implemented a six-month demonstration project in Huong Khe District, Ha Tinh Province, Vietnam, to assess the acceptability, performance, and impact on waste disposal of a manual needle remover introduced at commune health centers (CHCs). The evaluation identified opportunities for significant improvement in the management of medical waste at CHCs. Needle removers were found to be a technically appropriate and feasible solution for CHCs, accepted by most health workers and managers, and able to address problems of health care waste disposal in rural areas. Based on the results of this demonstration project, the evaluation team recommended broader introduction of needle removers in CHCs located in rural and mountainous regions of Vietnam. Training and maintenance are critical issues for ensuring successful introduction of needle removers. Should they be introduced more broadly, it would be important to strengthen supervision at the CHCs. Before any device can be introduced more broadly, an evaluation must be conducted to ensure that it is compatible with the types of syringes being used in Vietnam. Safety boxes continue to be an important tool for managing sharps waste in Vietnam. However, unreliable supplies (safety boxes are only supplied enough for immunization injections) and lack of final disposal options present challenges for use. Since this study was completed, needle removers have recently been included in draft health care waste management guidelines developed by the Ministry of Health as an option for sharps waste handling in CHCs in Vietnam. For more information about this evaluation conducted in Vietnam, contact [log in to unmask]">Huong[log in to unmask]"> Vu. For more information on needle removers, visit the Needle Remover Resource page published by PATH. This web page is intended to serve as a resource for countries and programs considering the introduction of needle removers. Visit the page Huong Vu, MD, PhD Senior Program Team Leader PATH Hanoi, Vietnam ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : [log in to unmask]">[log in to unmask] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org ______________________________________________________________________________ ======================================================================== Date: Thu, 21 Jun 2007 22:59:49 -0400 Reply-To: [log in to unmask] Sender: Technical network for strengthening immunization services Comments: RFC822 error: MESSAGE-ID field duplicated. Last occurrence was retained. From: TechNet Subject: POST 01109E : SOLAR REFRIGERATOR MIME-version: 1.0 Content-type: text/html; charset=iso-8859-1 Content-transfer-encoding: quoted-printable TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: [log in to unmask]">[log in to unmask] or use your reply button! __________________________________________________________ POST 01109E : SOLAR REFRIGERATOR Follow-up on Posts 01019E, 01027E, 01032E, 01037E, 01045E, 01095E and 01102E 21 June 2007 _____________________________________ This posting contains two contributions. The first comes from [log in to unmask]">S=F8ren [log in to unmask]">Spanner from UNICEF/India. The second is from [log in to unmask]">Gregory [log in to unmask]">Kiluva from UNICEF Supply Division _____________________________________ All the Solar Powered Refrigerators, listed in the PIS are working perfectly well. Provided that: The system is correctly sized. Installation is done as per manufactures recommendations Maintenance is done as per manufactures recommendations. Proper training of users. As for the size, if you need 30l buy 30l, if you need 50l buy 50l. A bigger SPR is more expensive than a small, like a house, car or whatsoever. As for Jharkhand, I could not disagree more see the reasons above. Solar panels might be stolen, so might generators. Many of the generators I have seen, in the same area are idle because of lack of fuel. I would question the cost effectiveness of the generator solution. Soren Spanner Project Officer Cold Chain Health Section, UNICEF, India Country Office, New Delhi -------------------------- Dear All, I have read the two contributions on this post and would like first to respond to Lydie. The three numbers you refer to in the Supply Catalogue refer to

TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: mailto:technet21@ccisd.org or use your reply button! __________________________________________________________ POST 01089E : NEEDLE REMOVER EVALUATION 6 May 2007 ____________________________________ Carib Nelson (mailto:cnelson@path.org) from PATH is sending this report of a new needle-remover evaluation conducted in Senegal. Please note that the document is heavy at 4.65 MB. ____________________________________ In July 2006, PATH conducted a qualitative assessment in Senegal of a new needle remover approach that is under development. This approach has the potential to dramatically reduce the cost of needle removal by providing a simple needle popper/cutter fitting that attaches to the opening of locally available containers such as jerry cans. The device consists of 3 parts: an adapter that fits into the mouth of the container, a needle popper to pop off detachable needles, and a simple scissors fitting to cut fixed-needle syringes. The scissors are reusable while the adapter and popper are discarded with the filled container to prevent access to the used needles. The anticipated cost of the device is US$1 for the adapter/popper and US$5 for the reusable scissors. Although this device is still in prototype phase, the assessment was held to evaluate acceptability of the approach and guide design refinement. The assessment was based on interviews and simulated use of the device with sterile syringes. A total of 70 participants took part in this evaluation. A detailed report is available from : http://www.technet21.org/fichiers_Word/NeedleRemoverSenegalEvalRpt2007.doc Summary findings: * The approach was highly acceptable to the health workers. Similar to findings from other needle remover evaluations, health workers valued the safety provided by immediate removal of the needle from the syringe. * Use of a locally available container allowed users to size their needle remover to their immediate need. For example a small container could be used for outreach or a large container for a clinic. * Proper assembly of the adaptor and popper onto the container was occasionally difficult for users -- some design refinement is required * Participants felt the target price was affordable. * A wide variety of plastic containers were purchased at a local market for the evaluation, and participants came to general agreement about the importance of certain features such as opacity and a wide base. The cost of the container was not seen as an impediment to purchase or use. * Final disposal of the filled needle container remains an unresolved issue. PATH is currently seeking funding to refine the design of the device, then hopes to identify a commercial partner for manufacture and to transfer the technology. Carib Nelson Team Leader, Technology Solutions PATH ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : mailto:LISTSERV@listes.ulaval.ca Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org)

POST 01056E : USE OF ALCOHOL FOR VACCINE INJECTIONS Follow-up on Posts 01029E, 01036E, 01044E and 01051E 20 February 2007 _______________________________ I thought that the last posting would end the debate on this topic. But three more contributions were received. The first is from Augustine Akubue (mailto:akubueaugustine@yahoo.com) from Nigeria. The second is from Oleg Benesh (mailtobenes@sanepid.md) from Moldova. And finally, a short comment from Lydie Maoungou Minguiel (mailto:lmminguiel@unicef.org) from Congo. _______________________________ It is important to note that despite the entire good scientific guess on the effect of Alcohol on immunization, no properly documented research has been carried out to support the claims or compare the AEFIs associated with each procedure. However, my experience in the field shows that most vaccinators carrying out outreach in Africa use alcohol as a matter of choice. Most people think that alcohol will be better than water just as traditions. In Nigeria, water is better in use than alcohol as many health facilities cannot afford alcohol at all times. Majority of patients living in villages do not take care of themselves hence water being a universal solvent will wash out dirt easier than alcohol. Alcohol when used in children with abnormally soft skin leads to skin excoriations. I observed that one health personnel who used alcohol instead of water in one remote village during an outreach immunization visits resulted in many injection abcesses. This got reduced immediately he introduced water instead of alcohol. It is worthy of remark that the most important factor is the method of cleaning the site than what is used to clean the site. Some health personnels do not know how to clean injection site. Many clean the site many times on two directions with one swab. I therefore advise all to stress on the cleaning procedures especially in Africa where many parents do no bathe their children regularly. Augustine Akubue ----------------------------- Dear all, The discussion on the use of alcohol for vaccine injections may come up repeatedly because injection is a medical intervention affecting integrity of the human body that might be accompanied by a range of risks, including the risk of introducing infection. Ethanol swabs are used in Moldova for vaccination injections for more than 40 years and we could not see any clusters of adverse event following its use. There are two main circumstances when alcohol swabs use might be justified for injections (including vaccination injections): 1. Clean the injection site prior to injection 2. Protecting the injection site from infection and bleeding after injection is done. To me is not acceptable to clean the site only when dirty as the microbial contamination of the site CAN NOT be detected visually. Applying a standard cleaning precautionary measure I consider A MUST, and I would not accept personally any injection before a precaution to prevent possible infection is taken? I also would like to ask how often the injection site is bleeding after injection. According to my observations it is a rare case for intra-cutaneous injections (BCG) and almost universal after subcutaneous or intramuscular injections. I would like to ask whether a child should leave the vaccination place with a bleeding injection site. And if not - let's decide how to approach it. I would appreciate the discussion addresses the alternative ways/methods/tools these two concerns are safely met. It is well known any drug can be the same time a poison if not appropriately used. The cited article on methanol use is a good example. To me the main problem is ensuring appropriate training of staff delivering health services (including vaccinations) on appropriate use of technology and appropriate logistical support to allow its implementation. I am not a supporter of promoting unjustified over-simplified techniques. Yes, such techniques can allow reaching high coverage, but I would not like the price we pay for is safety. Alcohol swabs, if properly used, beside cleaning the site have also some anesthetic effect and injection is less painful to the child and they are less exposed to the stress during the injection. Let me do not support the concern cited below: ... there is a potential for containers of alcohol-soaked swabs to become germ-breeding sites due to alcohol concentrations reducing over time (a particular risk in hot climates) with a resulting risk of cross infection.... First, if the swabs become germ-infected, that is good for children whose vaccination sites got clean of those germs. Secondly, safe vaccination programs have to address proper handling and disposal of biologically hazardous waste. I do not see any problem swabs are collected into safety boxes together with syringes and are disposed off afterwards following the country waste disposal policy. I also would understand that alcohol can inactivate live vaccines if there is a direct exposure of the vaccine to the alcohol. But is there any evidence the alcohol applied on the skin can inactivate the injected vaccine into the tissues? With best regards, Oleg Benes Medical epidemiologist, Republic of Moldova ------------------------------- Hello to all, I share Serge's opinion, I have not seen any study on this topic. Thank you, Lydie ______________________________________________________________________________ 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. The comments made in this forum are the sole responsibility of the writers and do not in any way mean that they are endorsed by any of the organizations and agencies to which the authors may belong. ______________________________________________________________________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : mailto:LISTSERV@listes.ulaval.ca Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org) ______________________________________________________________________________

POST 01051E : USE OF ALCOHOL FOR VACCINE INJECTIONS Follow-up on Posts 01029E, 01036E and 01044E 8 February 2007 ________________________________________ This posting contains three contributions. I believe that this will likely settle the issue. The first is from Serge Ganivet (mailto:GanivetS@whoafr.org) from WHO/AFRO in Zimbabwe. The second is from Anil Varshney (mailto:anilvarshney@yahoo.com) from India. Anil had contributed earlier to this discussion. Finally, Adwoa Bentsi-Enchill (mailto:BentsiEnchillA@who.int) and Diana Chang Blanc (mailto:ChangBlancD@who.int) both from WHO contribute an institutional reply. Please note that the most commonly used alcohol as an antiseptic is propanol or Isopropylic alcohol. ________________________________________ Dear all, I am quite surprise that after so many years of EPI we still don't have clear answer to that question. It has been raised so many times and no clear answer has been given so far. In the Vaccination Practical Guideline, it is mentioned only to "clean the skin with water if dirty, it is not necessary to use alcohol" I think that the main question about the cleaning of the skin (if dirty) is between water and alcohol and not between alcohol or nothing. The explanation I got since I work in EPI is that the alcohol does not clean better than water, alcohol could "disinfect / sterilize" the skin only if it is done properly (from top to bottom, etc.) which is not the case most of time and certainly not in 2-3 seconds, and most important alcohol can affect the quality of BCG vaccine that is administered intradermic. As far as I know there is no study showing that cleaning the skin with water is more risky than with alcohol. But using alcohol is more expensive, needs logistics especially for outreach activities, etc. Nevertheless the water should be clean but not necessary boiled. That is my understanding. Regards, Serge ----------------------- Hello All, In this reference please refer to my previous contribution, stating that if skin is clean nothing is necessary and cleaning with plain water is sufficient. In practice I have seen patients using a insulin needle for self-use for more than 6 times before discarding for to be replaced with new one, injecting without use of alcohol or cleaning with water, with no infection reported in last few years. The reason for using the same needle is the cost of needle at Rs. 10/- which is more than the cost of the insulin dose. regards, Anil -------------------------- Viral vaccines with glycoprotein coats ('live' vaccines), such as measles or yellow fever, are inactivated by alcohol. This is also relevant to the smallpox vaccine where the particular vaccination technique (multiple puncture) increases the potential for vaccine inactivation by alcohol at the site of injection (http://www.bt.cdc.gov/agent/smallpox/va ... method.asp). It is questionable whether the minute amount of alcohol that would come into contact with the tip of a needle could negatively affect bacterial vaccines and the subsequent immune response. We are not aware of specific or current literature on this issue. As recommended in the Australian Immunization Guidelines previously circulated by David Hipgrave/UNICEF and the Canadian Immunization Guidelines (http://www.phac-aspc.gc.ca/publicat/cig-gci/index.html), if alcohol or a suitable antiseptic is used, the swabbed skin should be left to dry before the injection is administered. Prior to the injection of vaccines, WHO recommends that skin not be swabbed unless it appears dirty, in which case it is sufficient to clean the surface with water. It is not considered necessary to apply alcohol to clean the skin. (Immunization in Practice, http://www.who.int/vaccines-documents/iip/PDF/Module6.pdf) In the broader context, WHO does not recommend use of alcohol swabs because of programmatic risks that can potentially lead to serious adverse events following immunization (AEFIs). While no published empirical data are known to us, there is a potential for containers of alcohol-soaked swabs to become germ-breeding sites due to alcohol concentrations reducing over time (a particular risk in hot climates) with a resulting risk of cross infection. The infection resulting from such contamination may be localized, or systemic such as in toxic shock syndrome. Additionally, from an operational standpoint, there is the risk that a product other than alcohol or other suitable antiseptic could be used mistakenly by the immunizer, with unintended consequences. Although not directly related to the question at hand, the following article describes an EPI situation where methanol compresses were used post-immunization, leading to fatalities (http://www.technet21.org/pdf_file/Inves ... ne2002.pdf) If swabbing of injection sites with alcohol or other antiseptic prior to immunization is part of national policy, the immunization programme should ensure that adequate control procedures are in place, or preferably use single-use pre-packed swabs. If such measures are not feasible or implementation is unsatisfactory, it is recommended that the procedure of swabbing skin with alcohol prior to immunization be abandoned. Adwoa Bentsi-Enchill, WHO/IVB/Quality Safety and Standards Diana Chang Blanc, WHO/IVB/Expanded Programme on Immunizations ______________________________________________________________________________ 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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