Dear all,  Can any one explain how the decision is made as to which type of VVM is assigned to different vaccines, with examples? Are same vaccines manufactured by different manufactures assigned different type of VVM? Thanks,  Chandralal

WHO PQS is conducting a survey to learn from users of Remote Temperature Monitoring Devices (RTMDs) and inform the future of vaccine cold chain monitoring. Have you ever… Received a text, email or notifications from an RTMD? Interacted with RTMD hardware in the field, including responding to alarms? Setup RTMD hardware and/or software? Interacted with an online RTMD web portal? Conducted repairs or service on RTMDs? If so, we want YOU to help inform the future of RTMDs! Interested? Please send an email to dhabimana@path.org to receive the survey link!  Best wishes, Denise Habimana Vaccine Cold Chain Technologies Program Officer at PATH

Finding the Perfect Temperature: Protecting Lifesaving Vaccines in Remote Areas
Immunization is one of the most successful and cost-effective public health interventions in history, saving 2-3 million lives every year. In Tanzania, JSI is installing remote temperature monitoring devices to strengthen the immunization cold chain and ensure that vaccines make it to the last mile. Click here to view the photo essay.  

Imagine that VVM’s do not exist. As an alternative a tiny electronic device could be developed which would record the temperature history of the vaccine vial. The device would be attached to the vial and graphically display the temperature history of the vaccine. If a health worker wanted to know how the temperature history of the vaccine would affect its life, how would they do it? This is essentially the same problem faced when trying to interpret the data obtained from a refrigerator or vaccine carrier data logger. Currently there is no analytic method to determine how temperature excursions affect the life of a vaccine. VVM’s A VVM may be thought of as an analogue device whose function is governed by the Arrhenius rate equation. The output of this elegantly simple device is a displayed dot of varying density. The density of the dot indicates the percent of life left in the vaccine. If VVM’s were not available the electronic device attached to the vaccine vial could use the collected data to calculate how temperature variations affected the life of a vaccine. This calculation could be done with the aid of the Arrhenius rate equation. The display of this device could mimic a VVM by displaying a dot of varying density to indicate how much vaccine life is left. However with digital electronics it may be more informative to display the number of days of life left. This same analytic tool could be used to interpret the data recorded on a refrigerator or vaccine carrier data logger. This would be a major step forward since there is no analytic method currently in use to determine how temperature excursions effect the life of a vaccine. ALARM SYSTEMS Knowing how temperature excursions affect the life of a vaccine can lead to more intelligent and responsive alarm systems. WHO recommends that an alarm is turned on when temperatures rise above 8C for 10 hrs. This recommendation could be misleading an alarm could be turned on when there are no problems and not turned on when there are serious problems. For example, for a 24 hours day an excursion to 9C for 11 hrs., then a return to 5C for 13 hrs. would turn an alarm on however this excursion would not lower the expected life of a vaccine. On the other hand if each day the temperature climbs to 20C for 9 hrs. in the afternoon, and than returns to 5C for the remainder of the day the alarm would not be activated,  however the life of the vaccine would be cut in half.  A DIGITAL ANALYSIS OF TEMPERATURE DATA BASED ON THE ARRHENIUS RATE EQUATION WOULD HAVE THE FOLLOWING ADVANTAGES:     Simplified data interpretation:  The analysis would show the effect of a temperature excursion in a simple to interpret form. The severity of a refrigerator problem would be indicated which is a valuable piece of information for management. Elimination of false alarms:  Alarms would coincide with indication from a VVM. More responsive alarm systems. Reduced vaccine waste. Data to show that outreach programs can be safely extended. Simpler and less expensive designs for refrigerators without sacrificing vaccine life These advantages could come to fruition if we simulated digitally what a VVM does in an analogue fashion. 

Dear Technet members, I would like to share my thoughts on the temperature monitoring devices and thermostal for vaccine refrigeration system. In the early days of EPI, temperature of the refrigerator was measured and displayed by a simple analogue thermometer which was either a bi-metal or stem type alcohol thermometer.  Twice daily the health worker records these temperature on the temperature monitoring sheet and posted on the door of the fridge.  Filled temperature records are collected, kept on the file at the end of each month and replaced by a new one.  Temperature recorded was the temperature obtained during that time when it was read.  There was no information on the temperatures during the night or between the time interval when temperatures were obtained.  These old thermometers need to be calibrated more often which was a big challenge at the remote health facility. To rectify the problem an electronic thermometer that could continuously record and display the temperature of the fridge was developed.  It does not need calibration till its lifetime of 2-3 years when it has to be replaced.  Average temperature readings could be read for the past 30 days.  The device was further developed to include a usb connector and with temperature alarm alert and temperature data could be downloaded for record and review purposes. The latest temperature monitoring and recording device has a temperature sensor placed inside the fridge and could send the temperature readings on a computer/cellphone and could further be accessed via cloud etc. All of the above temperature monitoring and recording devices are passive devices, in the sense that it does not take any corrective action if temperature excursions are encountered.  It is simply used to inform or alert the health worker that something is wrong with the fridge.  Corrective actions at health facility level relies on the health worker who is alone and frequently busy and not specifically trained to do the job of diagnosing the cause of the problem.  With shortage of the technical staff at the national/provincial/distric level, it is not expected to rectify the problem as early as it is needed thus causing potency problem to the vaccines, missed vaccine sessions and increase unopened vial vaccine wastage. Allow me to give information to each one who are not familiar with refrigeration system, that every vaccine refrigerator/freezer (with the exception of the absorption kerosene refrigerator) has a temperature control which is commonly called a “Thermostat”.  Thermostat is an active device (compared to a thermometer which is a passive device) which is connected in the electrical circuit component of the refrigerator.  Its main job is to regulate or control the temperature of the refrigerator according the temperature setting by the user.  The old thermostat control switch is numbered starting from 0 to say 5.  Each number has a corresponding cut-in and cut- out temperature. How does thermostat work? The purpose of all refrigeration system is to lower the temperature of the confined space below that of its immediate surrounding.  The confined space of the refrigerator is the vaccine storage compartment. The refrigerant compressor of the refrigeration system once connected to the grid or solar panel will continuously run to lower the temperature of the vaccine storage compartment thus putting the freeze-sensitive vaccines at risk.   Running compressor motor can be stopped by any of the following actions:  a) if power from the grid is manually disconnected by the user or accidental power shutdown; b) the overload protector of the compressor is automatically activated due to extreme heat and voltage fluctuation; and c) the thermostat which was set at a desired temperature is automatically activated. Please note that once the compressor is stopped by either of the above ways the temperature inside the vaccine storage compartment will continue to rise.  Operation of the refrigerator will commence again if either the refrigerator is manually connected to the grid, the overload protector cools down and voltage is back to the normal range or the thermostat automatically reach its cut-in set point.  Therefore, THERMOSTAT is an active device that automatically regulates the temperature between the cut-in temperature of +8°C and the cut-out temperature of +2°C of the vaccine storage compartment.  Cut-in temperature of +8°C is the temperature when refrigerator compressor motor will start and cut-out temperature of +2°C is the temperature when refrigerator compressor motor will stop to protect freeze sensitive vaccines from freezing. It is therefore very important call to action for the refrigeration system equipment manufacturer to further conduct a very thorough study to equip the vaccine refrigerator with a very accurate and precise thermostat control device that will work at various conditions in the field. WHO PQS has introduced new standards for refrigerators to have a sealed thermostat. This effort is highly appreciated hoping to reduce unopened vaccine vial wastage due to freezing temperature in the refrigerator.  If thermostat is not sealed untrained staff as in the previous refrigeration units will try to adjust the temperature setting of the thermostat thus placing the both freeze sensitive and not freeze sensitive vaccines at risk.  Electronic sealed thermostats are now used by equipment manufacturer.  Temperature settings of these thermostat can only be altered by a manufacturer trained technician. Recently, countries are receiving refrigeration equipment under the GAVI CCEOP project.  Equipment are laboratory tested and PQS compliant, however their performance could actually be tested at different and difficult environment and situations in the field.   To be able to assist the equipment manufacturer to develop a more accurate and precise thermostat, country’s EPI national program should monitor equipment performance and share feedback to TechNet for follow up actions. Hope this helps. Alejo H  Bejemino Consultant Medical Physics and Health Physics Services, Inc Philippines    

 I am setting up an alarm to indicate to high a temperature in a vaccine refrigerator.  I would appreciate it if someone could tell me the reccomended temperature and the time that  temperature must be maintained to set off the alarm?   My second question is if you what that time and temperature are based on?   Larry Schlussler       Sun Frost    

Bonjour Le Niger a entrepris en 2016 avec l'aide de ses partenaires la cartographie de la température dans ses Chambres froides. Nous avons beaucoup appris de cette expérience notamment sur : - La cartographie de toutes les chambres froides qu'elles soient anciennes ou nouvelles - Le réglage de la consigne d'arrêt des unités de réfrigeration - La fiabilité du Kit Berlinger (SmartView) Nous proposons les recommandations suivantes à d'autres pays intéressés par la cartographie de température : - Former les formateurs qui doivent poursuivre la cartographie dans le reste du pays - Doter l'équipe pays d'un kit de documentation et de matériels (kit log tag) - Installer des dispositifs de monitorage de température à distance dans toutes les chambres froides aux niveau central et régional. J'aimerai partager avec vous le resumé de cette activité dans le doucument attaché. Pour plus d'information ou de questions, veuillez contacter Abdoulaye Boubacar, Chef Service Logistique à la Direction des Immunisations, Niger, abdouboubacar01@yahoo.fr ou Cheick Tidiani Coulibaly Conseiller Technique, JSI Research & Training Institute, Inc. cheick_coulibaly@ne.jsi.com

The WHO UNICEF immunization Supply Chain Hub (iSC Hub)has released a new temperature monitoring website hosted on TechNet-21.
A stringent system for temperature surveillance is essential to maintain the quality of the vaccines in an effective Supply Chain. By preventing vaccine exposure to freezing or hot temperatures in the cold chain, a functioning temperature monitoring system helps ensuring vaccine potency, avoiding both wasting vaccine investments (notably through reducing closed vial wastage) and potentially placing children at risk of contracting vaccine preventable diseases.
This new areaof the TechNet-21 website stresses that effective surveillance depends on the development of a system of accountabilities, processes and equipment (in this order or importance) in order to ensure that temperature excursions are detected and that appropriate corrective measures are taken to avoid damage to the vaccines.
This website presents technical and programmatic information on available solutions to maintain vaccines in adequate temperature range at fixed storage and brings forward country experiences both on the use of 30DTR devices and RTM technologies. It aims at:

Providing decision makers and stakeholders with pragmatic step-by-step guidance and material to build a Temperature Monitoring system;
Encouraging experience sharing in order to leverage good practices and useful tools among countries and partners wanting to introduce or to update systematic temperature monitoring based on some of the technologies described.

You can access the website through the following link: http://www.technet-21.org/en/resources/temperature-monitoring
We hope you will find it useful and look forward to any feedback you may have.

Adama E. Sawadogo
Lead of the iSC Hub Strategic Focus Area
On temperature monitoring

Interesting study from Turkey aimed at providing an approach to determine the best temperature monitoring system for vaccine storage in a warehouse.
AbstractCold chain management is a specific part of supply chain management. Cold chain managementdeal with products that should be transported and stored in certain conditions. Monitoring thetemperature in cold chain is one of the most critical and important factors. Effective temperaturemonitoring systems are a must have for a successful cold chain management in companies, sodeciding on the best temperature monitoring system is a strategic decision. The aim of this study isto determine the best temperature monitoring system for vaccine storage in a warehouse. Whilethere are many different criteria for selecting among different temperature monitoring systems, amulti criteria decision making methodology is used and we evaluated four different temperaturemonitoring systems by using fuzzy analytic hierarchy process (FAHP). Fuzzy numbers are used forthe application of analytic hierarchy process (AHP), because fuzzy numbers enable the decisionmakers to deal better with the uncertain and vogue circumstances while selecting the besttemperature monitoring systems. Electronic thermometer data logger system, wired data loggertemperature monitoring system, wireless data logger temperature monitoring system and cloudbased data logger temperature monitoring system are chosen as alternatives. First, we determined 4 main and 14 sub-criteria that affect the selection process and then we applied fuzzy analytic hierarchy process for selecting the best temperature monitoring system. Cloud-based data logger temperature monitoring system is determined as the best alternative.

Following the success of the first training session in December, 2015 on the use of the MULTiLOG2 Remonsys Ltd is planning to run a second training session in August this year.
Purpose and Objectives of the Course
The objective of this course is to equip delegates with the ability to install, configure and to operate the MULTiLOG2 system, to enable them to train others to understand the technology and how they can use it to make the best use of the recorded information to protect the vaccines in their care.
Methodology
The course will be taught in English
A mixture of demonstration and hands-on training
A participatory approach will be applied during training sessions.
Training notes, manuals and handouts will be provided
Delegates Profile
Delegates should be field officers, either from local, national, regional, or international non-governmental organisations, independent companies or free lancers working in the cold chain.
Time Frame and Venue
Date of training: Thursday, 25th and Friday 26th August, 2016
Duration of training: 2 days. Location for training: Oxford, United Kingdom
Note: Delegates may require a visa so please apply early to your local British Consulate
Training Costs
There is no cost for the training course but attendees are expected to cover their own travel and accommodation costs They should bring with them a laptop computer running Microsoft Windows 7 or newer.
For further information: -
Please register your interest as soon as possible with Remonsys Ltd
E: info@remonsys.com
T: +44 1993 886996

WHO has just released a new infographic that summarises how health workers can use vaccine vial monitors (VVMs) to decide whether or not to use a vaccine vial. Most notably, it presents VVM colour change as a continuous progression, rather than as four distinct stages.

A VVM is a chemical indicator label attached to the vaccine container (vial, ampoule or dropper) by the vaccine manufacturer. As the container moves through the supply chain, the VVM records its cumulative heat exposure through a gradual change in colour. If the colour of the inner square is the same colour or darker than the outer circle, the vaccine has been exposed to too much heat and should be discarded.
The main purpose of VVMs is to ensure that heat-damaged vaccines are not administered. The VVM status is also used to decide which vaccines can safely be kept after a cold chain break occurs thus minimizing unnecessary vaccine wastage. In addition, VVM status helps the user decide which vaccine should be used first – a batch of vaccine showing significant heat exposure should be distributed and used before a batch that shows lower heat exposure, even if its expiry date is longer.
Please use the new infographic in guidance and training materials, and share widely. The infographic is available in English and French on the WHO website:
http://www.who.int/immunization/programmes_systems/supply_chain/resources/tools/en/index4.html

Dear TechNet Colleagues,   I would like to share with you a report on our latest cold chain maintenance investigation in Mozambique: "Why Fridges Fail Part 2: RTM Data for Maintenance". We are beginning to document how remote temperature monitoring data and dashboards can be used by maintenance technicians to significantly improve cold chain performance. This assessment follows up on the randomized control trial conducted in 2014-2015 with Village Reach, PATH, and the Ministry of Health in Mozambique which aimed to evaluate the impact of remote temperature monitoring (RTM) on vaccine cold chain equipment performance at the health facility level. That study showed that RTM with SMS alerts increased fridge uptime and reduced freezing (See Appendix I of the report for more details.)

However, even some fridges in the RTM intervention group had chronic problems and failed to achieve 95% uptime.

We launched this follow-up investigation to answer the question: Can maintenance + RTM lead to 95% uptime?

We were very happy to work with Soren Spanner, a global cold chain expert with decades of experience. Soren traveled to Mozambique from September 24 until October 14, 2015. He used ColdTrace data to identify 27 fridges that were failing and worked with the Ministry of Health maintenance technician to visit or remotely diagnose and fix as many fridges as possible. Soren remained active in fridge fixes, phone calls and follow-ups through the end of November.

Perhaps the most interesting finding was that distinct patterns in the RTM data (which we call “temperature data signatures”) can be used to remotely diagnose problems and enable remote fixes via phone calls to nurses in clinics. For the improperly adjusted fridges in this investigation, thermostat adjustments increased uptime by 30%. Today, the MOH technician continues to use the dashboard data to diagnose problems, call clinics to address the issues, and verify fixes by monitoring subsequent temperature data. We also learned that, without access to key spare parts/tools, even an expert technician cannot get all fridges to 95%: flat batteries on solar fridges were one such problem that Soren did not have the resources to fix. With RTM data, however, those responsible for cold chain maintenance can identify which fridges need help and determine where to focus resources.

This report features all causes of fridge failure that the Technicians encountered, several key screenshots from the ColdTrace web dashboard, and critical recommendations for how to procure for and improve cold chain maintenance capacity at every level of the health system moving forward. We hope you’ll find these results approachable and easy to understand. I would greatly appreciate your feedback on the report and I hope we can start a discussion here on how temperature monitoring data could improve maintenance. Thank you. Regards,
Shahrzad

Dear colleagues: The Alliance Data for Management (D4M) working group is developing a guidance package on immunisation supply chain dashboards that includes a menu of primary supply chain performance indicators for countries to select from that meet their needs. The indicators and dashboards are intended for managers at multiple levels of the immunization supply chain and provide visualisation examples and suggested corrective actions for each indicator. This guidance will be endorsed by the Alliance Partners (WHO, UNICEF, Gavi Secretariat, BMGF). We want your input and feedback to inform the guidance and proposed indicator menu to make the guidance document as relevant and useable as possible! Survey will close Monday, June 1 https://www.surveymonkey.com/s/JFRGZXV For those that have already completed the survey, thank you! For others, we thank you in advance for taking time to provide valuable feedback to us.The survey should take less than 15-25 minutes to complete. For further information on the guidance document and how to get involved contact: Jan Grevendonk (grevendonkj@who.int, WHO), Dorthe Konradsen (dkonradsen@unicef.org, Unicef SD) Kaleb Brownlow (kbrownlow@gavi.org, Gavi) or Anna Rapp (anna.rapp@gatesfoundation.org, BMGF). Best, D4M working group

WHO and UNICEF have jointly prepared an information bulletin which addresses varied implications of different types of vaccine vial monitors (VVMs), notably VVM category type 7 (VVM7) and VVM category type 14 (VVM14), on vaccines such as the Inactivated Polio Vaccine (IPV) and the fully-liquid Diphtheria-Tetanus- whole cell Pertussis-Hepatitis B-Haemophilus influenzae type b (DTP-HepB-Hib, commonly referred to as pentavalent). The note is directed to countries that are currently supplied by UNICEF Supply Division with these specific presentations of vaccine. The information is intended for WHO/UNICEF staff, as well as EPI managers or other partner agencies which support immunization programmes.

Both the english and french versions are attached here.

Many thanks to Umit Kartoglu for sharing these videos with the TechNet-21 forum! WHO/EPELA releases the most recently produced expert videos on VVM-based vaccine management. These videos are specifically produced for the new EPELA authentic e-learning course on vaccine vial monitor-based vaccine management. The new course will be offered for the first time from 27 January to 28 March 2014. If you are interested in the other courses in 2014, please visit [url=http://epela.net/epela_web/evvm.html]visit http://epela.net/epela_web/evvm.html Both WHO and EPELA encourage others to widely use, share the videos and embed them in other websites. The following videos are now available publicly: A year in the life of a vaccine: Kevin O’Donnell [vimeo]58148553[/vimeo] Kevin O’Donnell reviews the role of VVM and how it can be the answer to increase access and ensure quality of vaccine was not compromised due to unacceptable heat exposure. Cold chain challenges everywhere: Simona Zipursky [vimeo]58148554[/vimeo] Simona Zipursky reviews the cold chain challenges to demonstrate that problems are both in developing and industrialized countries and questions whether VVM should also be the answer for both. How does a VVM work?: Denis Maire [vimeo]58747176[/vimeo] Denis Maire summarizes the technical characteristics of VVMs and explains how they work. Interpretation of VVM in relation to other temperature monitoring devices: Umit Kartoglu [vimeo]58156915[/vimeo] Umit Kartoglu reviews temperature monitoring devices used in a typical vaccine cold chain and analyses how the readings relate to each other when there are more than one device at a particular point. This analysis is done from the VVM perspective. Using VVM as a stock management tool: Umit Kartoglu [vimeo]58161022[/vimeo] Umit Kartoglu reviews the requirements for product arrival, storage and dispatch and analyses the role of VVM in effective stock management for each step. Special emphasis is given to the relation of VVM and expiry date in illustrating how VVM over-rules earliest expiry first out principle. Vaccines beyond the cold chain: Simona Zipursky [vimeo]58148555[/vimeo] Simona Zipursky reviews the studies on taking vaccines beyond the cold chain all published in peer-review journals and comments on how VVMs could be instrumental in these operations. VVMs getting smarter: Umit Kartoglu [vimeo]58161023[/vimeo] Umit Kartoglu reviews the recent changes in integrity and location of VVMs and the new message VVM is giving whether a vial containing multi-dose vaccine following opening can be kept for a subsequent session or not. VVM use at the most periphery: Serge Ganivet [vimeo]58680045[/vimeo] Serge Ganivet reviews the VVM use at the most periphery through different examples and brings new perspectives on how to make best decisions based on the expiry and VVM readings.

Project Optimize is seeking real-life stories of how vaccine vial monitors are making an impact in the field. If you would like to share your story, please reply to this forum post. Dont hesitate to also post photographs if you have some Thanks in advance Michel Zaffran

China considers VVMs by Qiyou Xiao, China National Biotec Group; Shuyan Zuo, WHO China; and Jack Zhang, PATH China In June, the first national seminar and information session about the necessity and feasibility of using vaccine vial monitors (VVMs) on domestically produced vaccines used in China was hosted by the Sinopharm Group. While the purpose of the meeting was exploratory, Sinopharm representatives indicated a two-fold interest in VVMs that has been growing over the past four years: (1) to improve the quality assurance of the vaccine cold chain in China, and (2) to prepare to enter the international vaccine market as a supplier to the United Nations Children’s Fund (UNICEF). The Sinopharm Group (http://www.sinopharm.com/p391.aspx) is China’s largest pharmaceutical and health industrial group under the State-Owned Assets Supervision and Administration Commission of the State Council and parent company of six of China’s largest manufacturers of Expanded Program on Immunization (EPI) vaccines. More than 60 people gathered in the city of Changchun including representatives from the Ministry of Health, China’s Center for Disease Control and Prevention (http://www.chinacdc.cn/n272562/index.html), China’s State Food and Drug Administration (http://eng.sfda.gov.cn/eng/) (SFDA), TempTime (http://www.temptimecorp.com/PublicPages/About-Temptime.aspx) (makers of HEATmarker® VVMs), Parteurop (http://www.parteurop.fr/), EuraBioLife, the six government institutes that manufacture vaccines a! nd biological products under the Sinopharm Group, and the China offices of the World Health Organization (WHO) and PATH. The representative from the Chinese SFDA discussed the need to improve vaccine quality, enhance the vaccine cold chain, and strengthen the public’s opinion of vaccine quality and safety. Implementation of VVMs would help to achieve these goals. Since 1996, WHO and UNICEF have specified VVMs to be affixed to vaccines (http://www.who.int/vaccines-documents/DocsPDF99/www9924.pdf)prequalified for EPI vaccination campaigns. VVMs are now on 98 percent of vaccines procured internationally through UNICEF’s Supply Division. Over the last six years the number of VVMs supplied has increased from 180 million to over 420 million per year. The Ministries of Health of Indonesia and India have required VVMs on all domestically produced vaccines for use within the country for several years. If China follows suit, three of the world’s most populous countries will have shown great leadership in adopting a proven technology to improve vaccination program effectiveness and access to immunization. We invite you to comment on or post a question relating to this article by clicking the “post reply” button on this page. You will have to log in or register; the process is very simple. Return to the Optimize newsletter.

POST 01278E: VVM REFERENCES—ADDENDUM FOLLOW-UP ON POST: 01277E 11 JUNE 2008 ******************************************* Dear moderator, The first reference as indicated at the end of the below posting is an old document that is NOT valid any more. It seems that this document has slipped through web pages that we have to identify and delete. The correct address of this document was in my message. I am repeating it here again for easy reference: http://www.who.int/entity/immunization_standards/vaccine_quality/who_pqs_e06_in05_1.pdf I would also suggest the following main page on VVMs (with many links) at the WHO web site: http://www.who.int/immunization_standards/vaccine_quality/vvm_10years_index/en/index.html It is also worth warning the readers that 2002 documents are historically important documents, however, some of the information indicated in those documents apply to 2002 and not to today. TechNet21 members should read these documents with this in mind. Many thanks, UMIT ([email=kartogluu@WHO.INT]kartogluu@WHO.INT[/email]) Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01277E: VVM—A WHO-PREQUALIFIED AND VALIDATED TOOL FOLLOW-UP ON POSTS: 01264E, 01266E, 01275E 10 JUNE 2008 ******************************************* The query regarding VVM reliability has generated a fair number of responses--a few heated ones too. An interesting diversion here before we take the bull by its horns: the VVM is older than the TechNet e-forum (used on UNICEF-supplied OPV vials since 1996). For those of you who have an historical bent of mind, a chronological detail to share: the TechNet e-forum was originally the VVM forum. In June 1998, it became the TechNet forum (and had 145 members). Now to come to the point. The VVM has been discussed extensively on this forum earlier. It is a much tried and tested tool, and extensive field use has established its usefulness. All the same, questions like those raised by Dr Sood should not be perceived as a threat to VVM use; they, hopefully, will help clarify issues and make the case for VVM stronger. And it is better that these perceptions get clarified, especially since they are unscientific. The e-forum is a space for sharing knowledge and field experiences, and this space is generally respected and valued. Errors, if any, are of omission. A list of must-read documents has been included for those who would like to re-familiarize themselves with the issues. ----------- Dr. Sood has once again raised a point which has been discussed time and again in India. The narration is comprehensive and covers different aspects. Has GOI/IAP accepted open vial policy in non-NID settings for OPV? The colour change in VVM to grade III/IV on a OPV vial certainly is a definite indicator for field workers for not using the vial. And also for program managers at all levels to look into the cold chain from manufacturer till it reaches beneficiary. It is true that 4 frozen ice packs is the best indicator for routine immunization but in NIDs/SNIDs where massive resources are required VVM still seems to be a good proxy indicator. S. C. Gupta ([email=scgupta1scg@GMAIL.COM]scgupta1scg@GMAIL.COM[/email]) Jaipur, India Dear Technet, Your reader comment on the reliability of the VVM is useful if it guides your readers towards the WHO review document, "Thermostability of Vaccines,"which your readers can view at http://www.who.int. See the discussion on OPV degradation at different ambient temperature levels, starting on page 30. Briefly, the field guidelines for vaccines are much more rigorous than the thermostability of vaccines would warrant. This simply reflects the desire to err on the side of caution. Specifically, OPV can, for hours at a time, stand in ambient temperatures. This explains the use of the fast chain in areas without good peripheral cold chain in remote areas. This is no argument for putting OPV in your shirt pocket when a refrigerator is available. It is a strong argument for not tossing out vaccines when the VVM is at Stage 1 or 2. Bob Davis ([email=rdavis@UNICEF.ORG]rdavis@UNICEF.ORG[/email]) American Red Cross Nairobi Dear Moderator I am deeply concerned at the isolated posting of this unscientific, alarming and alarmist anecdote of one group's experience with VVMs. The VVM is a WHO-verified device, which has, within the limitations of batch-to-batch reliability and lot quality assurance, been verified to perform within certain parameters of temperature and light exposure. As you would know, there are four varieties, each of which vary in the rate of colour change according to their photochemical and thermochemical properties, and which in turn determines which type is applied to which kind of vaccine vial (according to the stability of that vaccine). This is clearly outlined in the attached references, and should be understood by all users of VVMs. You might also like to familiarise yourself with the technical information previously provided to me by the manufacturer and from WHO, as referenced below. Sorry I don't have electronic versions of these references. (Has been included in the list below.) I would strongly recommend you to batch the posting of these responses more responsibly, or preferably just refer them to Ms Robertson or Dr Shapiro as originally requested. As Hans Everts pointed out in the earlier posting, it takes a lot to change people's established practices in EPI, and although due care is appropriate in use of VVMs, the isolated experiences of one group (just like those of individual members of the anti-vaccination lobby in relation to immunisation itself) can frighten off a lot of people who would otherwise have used VVMs, as intended and with great benefit to infants and young children around the developing world. David Hipgrave ([email=dhipgrave@unicef.org]dhipgrave@unicef.org[/email]), Chief, Health, Nutrition and WES Section UNICEF China 12 Sanlitun Lu, Beijing China 100600 Dear Moderator, Having spent considerable amount of time managing TechNet21 at WHO HQ (2001-2006), I always believed that we established a working ethic to encourage participation from all levels. However, when it comes to UNSCIENTIFIC contributions, we have to be careful... Encouraging participation should NOT be practiced blindly... It is our responsibility to filter such contributions, otherwise, they will create more CONFUSION and HARM than anything. If one looks back in TechNet21 archives, he/she can find many postings in response to this unscientific contribution. VVM was conceived as a dream in 1979... In May 2007, we have celebrated 10th year of VVM introduction... During its 10-year implementation period, around 2-billion units of VVMs were made to the field, helping health workers to take informed decisions... VVM specifications and verification protocol can be found at the following WHO site: VVM is a prequalified device by the WHO. Validation tests were conducted at independent WHO accredited laboratories. In addition to these tests, all batches are released one-by-one by the manufacturer Temptime Corp., using accelerated tests as well as accepted by vaccine manufacturers through similar tests. There are also a series of random testing of VVMs from the field showing conformity with WHO specifications. Lot release tests are done at 37°C while validation tests are conducted at lower temperatures such as 25°C, 8°C and 5°C. VVM reaction is based on Arrhenius equation which is correlated to vaccine degradation due to heat exposure. In summary, VVM mimics this degradation with a safety margin. The correlation between VVM and the vaccine potency was studied by the WHO and published. This study was first presented at the TechNet Copenhagen meeting in 1998 and was then published by WHO as Testing the correlation between vaccine vial monitor and vaccine potency (WHO/V&B/99.11). The study was designed and evaluated by D J Wood of the National Institute for Biological Standards and Control (NIBSC) in the United Kingdom. The study showed that there was a good correlation between vaccine potency and VVM change for vaccines produced by all four OPV manufacturers supplying vaccine to UN agencies. Since the principle of correlation has been established, WHO did not see any need to further test the potency of each vaccine relative to the VVM response (the relative temperature dependence of VVM reaction (Arrhenius activation energy, remains essentially the same in all four different types of VVMs; however the rate varies with VVM category). In the past, we have seen people dumping the vaccine vials with VVMs in boiling water or in extremely hot ovens claiming that VVMs do not react to these exposures. These unscientific experiments are not pertinent to field conditions. VVMs were tested after submersion in water according to the approved protocol and they conform to the requirement. The manufacturer uses in-process testing of VVMs during production at 60°C and higher. Since we do not keep vaccines in boiling water and/or in hot ovens, I have difficulty in understanding the logic of exposing VVMs to such conditions. Similarly, taking a vial with VVM and exposing it to undefined and uncontrolled temperature will not work to challenge the science behind VVMs (no information was available on the type of VVM, duration of exposure, ambient temperature profile, etc.). If Dr Rajesh K Sood is interested, I strongly suggest him to read the specifications and verification protocols to understand how these tests should be conducted. Since Arrhenius equation is a mathematical calculation, when the temperature exposure over time is known (but the temperature exposure the vaccines most likely to be exposed to - not boiling water or hot oven temperatures), the VVM reaction can be mathematically calculated. This was also tested in a series of laboratory controlled and field studies between 2002-2004, that authors confirmed the perfect match of VVM color change and mathematical calculations (Kartoglu U, Ganivet S, Guichard S, Aiyer V, Bollen P, Maire D and Altay B. Use of cool water packs to prevent freezing during vaccine transportation at the country level, PDA Journal of Pharmaceutical Science and Technology, in press 2008). In summary, the science behind VVM brings together 29 years of experience and many tests at all levels, at the manufacturing facility, independent laboratories, vaccine manufacturers, random testing and field studies. VVM is a validated and prequalified time temperature indicator serving for more than 10 years to health workers to make correct decisions when a vaccine is exposed to a combination of temperature over time. There is absolutely no question about the reliability of VVMs. Dr Sood's contribution has another UNSIENTIFIC statement (or suggestion) - that is to "insist on 4 well-frozen icepacks". This is how you invite "freezing". But this deserves a separate discussion. UMIT KARTOGLU Scientist FCH/IVB/QSS, Room L267 World Health Organization References [list=1] WHO Specifications for VVM: http://www.who.int/immunization_standards/vaccine_quality/vvm_specifications_e6in5.pdf WHO Technical Session on VVM: http://www.who.int/immunization_standards/vaccine_quality/08_questions_and_answers_21march02.pdf WHO policy statement (MDVP): http://www.who.int/vaccines-documents/DocsPDF99/www9924.pdf VVM History and Milestones http://www.who.int/entity/immunization_standards/vaccine_quality/VVM_history_milestones.pdf Temperature sensitivity of vaccines: http://www.who.int/vaccines-documents/DoxGen/H3DoxList.htm http://www.technet21.org/fichiers_Word/VVM-Interpretation.doc (550K) (POST 01061E: VVM USE) [/ol] Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01275E: HOW RELIABLE IS THE VVM? FOLLOW-UP ON POSTS: 01264E, 01266E 4 JUNE 2008 ******************************************* Rajesh Sood raises questions about the reliability of VVM in the context of out-of-cold-chain practices and recommends conventional safeguards. ----------- We have found that VVM does not change colour even when exposed for long to room temperature and even sunlight. The VVM on used vials lying on the table in NIDs do not change colour-- which leads to skepticism on the real predictive value of VVM for vaccine cold chain status. Conventional wisdom states that is it is better to err on the side of more caution, and insist on 4 well-frozen ice packs. We rely on VVM as a proxy indicator of extreme or prolonged heat exposure before reaching the point of delivery, a problem over which the frontline staff have no control. We still have doubts regarding open vials policy in non-NID settings for OPV. Dr Rajesh K Sood ([email=drrksood@gmail.com]drrksood@gmail.com[/email]) India ----------- Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01266E: BROADENING THE USE OF THE VVM 16 MAY 2008 FOLLOW UP ON POST 01264E: ******************************************* Hans Everts responds to Joanie Robertson’s request for out-of-cold-chain vaccine distribution experiences and asks for a proactive approach to VVM. He says the need is to find the right balance between micro-planning and prescriptive policy. Theo Wirkas writes to say that he will be closely following the OCC experiences discussed on TechNet. Anil Varshney seeks information on vaccine holding capacities of WICs, DFs and ILRs of the different brands. ----------- Regarding VVM OCC experience, this is what I wrote in POST 01042E in January 2007: QUOTE: Referring to the comments by Subhash C Choudhury on India, I think the vaccinators made a wise decision. The advantage of the VVM is not only to passively monitor the cold chain, but at least if not more important, to actually find solutions to problems in operational campaign implementation, beyond simply stopping the vaccination. There is a lot of - undocumented - experience, in particular in the African Region in the use of VVM for polio campaigns: [list=1] use of non-PIS (PQS) quality vaccine carriers to conduct polio SIA; [/ol] [list=1] teams not returning to their base for renewal of ice after it has melted and therefore being able to continue vaccination; [/ol] [list=1] vaccine carriers with only 1 or 2 icepacks, rather than 4, in particular for urban teams; [/ol] [list=1] teams splitting up at markets and bus stations, while one member keeps the vaccine carrier and the other simply relies on the VVM; [/ol] [list=1] teams going to remote villages, beyond the cold life of the vaccine carrier; [/ol] [list=1] teams keeping the vaccine cool by other means, like digging a hole in the ground, keeping it in clay pots, etc. [/ol] All these experiences may not be useful or necessary everywhere, but so far Asian countries have taken a much more conservative attitude towards proactive use of VVM as an operational planning and implementation tool rather than as a mere monitoring tool. I have seen teams split up on markets taking advantage from the VVM in India, but that is considered an exception to be prevented, rather than the seed of a new operational approach. Applying VVM in a proactive way, including vaccine out of the cold chain, is a change in paradigm from the top-down classical cold chain. Progress is certainly not as much as I would have liked it to be, but I do believe that at least the mental paradigm change has taken place, even though it is only put into practice sporadically. When I did Out-of-Cold-Chain presentations late 20th and beginning 21st century, I risked my life, whereas now, people may still not implement it and be skeptical, but there is an openness that did not exist earlier. UNQUOTE Proactive use of VVM implies exploring the potential of the VVM on basis local conditions. As such, it can hardly be a national standard policy, except for transport and general guidance. It should be integrated in a micro planning approach like the one used for RED. The difficulty lies in finding the right balance between autonomous decision-making at a decentralized level and the need and sometimes even the preference for a central standard and prescriptive policy. Micro planning exercises in polio campaigns have shown that autonomous decentralized decision making can be extremely powerful and effective. Broadening the use of VVM continues to be one of the most exiting topics in vaccination policy, according to me. Hans Everts ([email=evertsj@WHO.INT]evertsj@WHO.INT[/email]) WHO Geneva Technical officer EPI +41 22 791 3683 ------ Dear Moderator, Joanie’s query concerning OCC is interesting. My country has not implemented OCC but there are possibilities. I would be closely following the subject. Thanks and all the best, Theo Wirkas (Mr.) ([email=twirkas@cbsc.org]twirkas@cbsc.org[/email]) EPI – Papua New Guinea ------ Dear Padmini I wanted to know the Vaccine holding capacities of WIC, ILRs and deep freezers of different make as I am unable to get the UNICEF PSQ catalogue. regards Anil Varshney ([email=anilvarshney@yahoo.com]anilvarshney@yahoo.com[/email]) Post generated using Mail2Forum (http://www.mail2forum.com)

POST 01117E : VVM ANNIVERSARY Follow-up on Posts 01101E and 01106E 5 July 2007 _____________________________________ Ümit Kartoglu from WHO/HQ replies to [log in to unmask]">Robert [log in to unmask]">Steinglass _____________________________________ Dear Robert, Thank you for your kind words for the 10-year anniversary's VVM global event. I also thank you for raising these concerns regarding the policy statement. In freeze-dried presentations, VVMs are placed either on the top of the vial or on the neck of the ampoule. VVM can ONLY be referred to until the time of reconstitution. With reconstitution, the section where the VVM is on is removed (you have to break the flip-off, or break the neck and then throw away these parts). After reconstitution the vial must be kept cold and cannot be used beyond six hours. Since there is no visible VVM on the vial, naturally, VVMs cannot be referred to. This section in the joint policy statement describing "special circumstances" is taken from the "Getting started with vaccine vial monitors ( WHO/V& B /02.35)" manual page 9. This means, these were WHO recommendations since 2002, now they are also spelled out in a policy document. The very beginning of the policy statement also refers to the same document. In the technical document "Getting started with vaccine vial monitors ( WHO/V& B /02.35)", after listing these circumstances, the following note is given: "Remember that freeze-dried vaccines (measles, BCG, yellow fever, and freeze-dried formulations of Hib) should not be transported to their point of use if the availability of ice cannot be guaranteed. Ice is necessary in order to keep the vaccines cool after they have been reconstituted." I am sure we all appreciate the difference between "policy statements" and "technical documents/guidelines" explaining "how to". With warm regards, Dr Umit Kartoglu ______________________________________________________________________________ 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 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 Robert 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 : [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 ______________________________________________________________________________ ======================================================================== Date: Sun, 17 Jun 2007 23:26:14 -0400 Reply-To: [email=technet21@CCISD.ORG]technet21@CCISD.ORG[/email] 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: [email=technet21@ccisd.org]technet21@ccisd.org[/email] 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 Anil 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 Hans Everts and Jacqueline Fournier-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 : [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 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: [email=technet21@CCISD.ORG]technet21@CCISD.ORG[/email] 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: [email=technet21@ccisd.org]technet21@ccisd.org[/email] 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 Huong 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 Huong 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 : [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 ______________________________________________________________________________ ======================================================================== Date: Thu, 21 Jun 2007 22:59:49 -0400 Reply-To: [email=technet21@CCISD.ORG]technet21@CCISD.ORG[/email] 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: [email=technet21@ccisd.org]technet21@ccisd.org[/email] 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 S=F8ren Spanner from UNICEF/India. The second is from Gregory 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

OST 00101E : VVM ANNIVERSARY 2 June 2007 __________________________________ NOTE : I will be away for about one week in remote areas, and may not have access to Internet. Consequently, TechNet may be silent for some time. I have to use Webmail today and no function to insert links. So all links will appear in the text in full, as before. __________________________________ WHO celebrates 10-year anniversary of VVM implementation Vaccine vial monitors (VVM) were introduced in 1996 through UN procurement agencies. The VVMs serve primarily to warn health workers when the cumulative heat exposure of a vial of vaccine has exceeded a pre-set limit, beyond which the vaccine should not be used. In addition, changes in the appearance of the VVM before this limit is reached will serve to guide health workers to first use more exposed vials of vaccines. Thus, the VVMs have ensured that the administered vaccine has not been damaged by heat, saved money through reduced vaccine wastage, facilitated immunization outreach services and helped to effectively manage vaccine stocks. Today, all vaccines (with a couple of exceptions) come with VVMs through UN procurement agencies. There is also a 20-year development history behind this successful implementation. In order to mark the 10 years of successful implementation of VVMs and to acknowledge the efforts put into this device by individuals, organizations, institutions and manufacturers, a celebration event took place in Geneva on 3 May 2007. Following this event, a similar event will be organized in the USA as part of the Global Health Council - Partnerships Working Together conference on 29 May-1 June 2007 hosted by PATH, along with another event in India later this year. With the event, WHO and UNICEF announced a new policy statement (http://www.technet21.org/pdf_file/VVM_j ... t_2007.pdf , 810K) focusing on the future of VVM, urging Member States to include VVMs in all tender documents, as well as urging donors to adopt a donation policy for inclusion of VVMs in all vaccine donations. The event brought together around 120 representatives from diplomatic missions to the UN, countries, vaccine manufacturers, public sector agencies, donors and individuals. The celebration event was chaired by Ms Daisy Mafubelu, Assistant Director-General, Family and Community Health. Following the opening remarks by Ms Mafubelu, the video "Five Senses" video, shot in Viet Nam, Niger and Indonesia early this year, was shown. The film focuses on how VVM helps countries to reach more children by simply relying on the effective use of VVMs (directed by Umit Kivanc). The story of the FIVE SENSES video can be downloaded from http://www.technet21.org/pdf_file/VVM_Five_senses.pdf Following the movie four speakers gave a brief history of VVMs: Debbie Kristensen from PATH focused on the problem definition that emerged from VVM development (1979-1989); Ted Prusik from Temptime Corporation talked on the solution, the VVM; Dario Cresci from Novartis brought the industry response in implementing VVMs and how the challenges were handled in applying the monitor on vials; and Mercy Ahun from GAVI talked on the field benefits. To acknowledge the efforts put into this tool, WHO distributed recognition certificates to countries, organizations, agencies, and individuals for their contribution to development and early implementation of VVMs (see the full list of recipients at : http://www.technet21.org/pdf_file/VVM_Recognition_certificates.pdf A photo exhibition entitled Five Senses by Umit Kartoglu, Jean-Marc Giboux, Philippe Blanc and Gencer Yurttas on the use of VVMs in the field was opened in the main entrance of the main building from 3-11 May. Clicking here, you can view the press release and a photo essay on VVM use. http://www.who.int/mediacentre/news/notes/2007/np21/en/index.html http://www.who.int/features/2007/vvm/en/index.html For the Geneva event, Ümit Kartoglu talked to John Lloyd, Michel Zaffran, Peter Evans, Julie Milstien and Dario Cresci on VVM history. Lloyd, Zaffran, Evans and Milstien worked together in WHO HQ on VVM during its early development stages as well as its implementation. Cresci was on the other side of the table - the industry. In 2001, Kartoglu joined the team, but after the departure of Lloyd and Evans from WHO. The following interviews bring interesting stories to daylight. When Kartoglu asked what was next, Lloyd, Zaffran, Evans, Milstien and Cresci all stressed the same point: using VVM to allow immunization programmes to exploit the stability of each vaccine. To use it to the greatest possible extent to minimizing distribution costs, and increasing flexibility in the handling of vaccines in the field, thus helping to make operations more effective. They all agreed that the mission is now reducing the dependency on the cold chain. VVM is seen as the answer to this challenge. To read these interviews click on the corresponding links below. http://www.technet21.org/pdf_file/VVM_john_Lloyd.pdf http://www.technet21.org/pdf_file/VVM_Michel_Zaffran.pdf http://www.technet21.org/pdf_file/VVM_Peter_Evans.pdf http://www.technet21.org/pdf_file/VVM_julie_Milstien.pdf http://www.technet21.org/pdf_file/VVM_Dario_Cresci.pdf Umit Kartoglu ______________________________________________________________________________ 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)

Content-Type: text/html TECHNET21 E-FORUM Technical network for strengthening immunization services Contributions to: mailto:[log in to unmask] or use your reply button! __________________________________________________________ POST 01061E : VVM USE Follow-up on Posts 01028E, 01035E, 01042E, 01050E and 01053E 3 March 2007 _______________________________ This posting starts with a contribution from Giridhara Babu ([email=%3Ca%20href=][log in to unmask][/email]" eudora="autourl"> mailto:[log in to unmask]) from India, followed by a comment from Josoa Ralaivao ([email=%3Ca%20href=][log in to unmask][/email]" eudora="autourl"> mailto:[log in to unmask]) from Madagascar. Then Ümit Kartoglu ([email=%3Ca%20href=][log in to unmask][/email]" eudora="autourl"> mailto:[log in to unmask]) from WHO Headquarters is sending a long and important document that develops a new approach of VVMs interpretation. At the same time he replies to Idrissa Yalcouyé and to this contribution of Giridhara Babu. As it is relatively heavy, it is hosted temporarily on our site and you can download it directly from : [url=http://www.technet21.org/fichiers_Word/VVM-Interpretation.doc]http://www.technet21.org/fichiers_Word/ ... tation.doc[/url] (550K) Finally, Diana Chang Blanc shares an article related to this topic, "Relationship between vaccine vial monitors and cold chain infrastructure in a rural district of India", by Y. Samant, H. Lanjewar, L. Block, D. Parker, B. Stein and G. Tomar ; Rural and Remote Health 7: 617 (Online) 2007. It is available online at : [url=http://www.rrh.org.au/publishedarticles/article_print_617.pdf]http://www.rrh.org.au/publishedarticles ... nt_617.pdf[/url]_______________________________ Thanks for the comments made regarding VVM use. I personally think that VVM is the best invention made in the recent history of Medicine, which has larger implications of doing common good to all without any discrimination. Whoever discovered it first, should receive Noble for Peace (since it is so universal in nature) and WHO has to share the any greater award for convincing whole lot of nations to follow this standard. However each great invention, greater scientific advancement comes with some limitation attached to it. Thanks to Mr.Hans Everts for useful points. I would like to answer regarding the objections against icepacks. 1. Use of ice packs is ideal under ideal conditions. But, the strict guideline to adhere the use of icepack leads to many confusions in the field. The innovations (with right intention but guided by lack of rational knowledge) by field personnel leads to use of ice blocks rises out of necessity to match lack of ice packs in the field. In India, a team which covers a booth and 250 houses in a day (for 4-6 days) require around 24-30 frozen ice packs just to maintain the cold chain within vaccine carrier. 2. There are not enough ice packs supplied all the time to sustain such huge requirement throughout the country. 3. Sometimes in the field, people use frozen ice packs to keep the vaccine outside at the cost of ice packs required to maintain cold chain for the rest of vials in the carrier. 4. National Polio Surveillance Project- India, a joint collaboration of WHO and Govt of India has come out with guideline of not to use ice packs based on all these limitations in the field. I agree with Dr.Vijay Kiran who has mentioned that a hand book on the cold chain would be useful to start with. However I feel that, conscious effort has to be put into streamlining the awareness and knowledge among private practitioners. Wider inter sectoral collaboration with with premier agencies involved in Pediatricians and other health care providers will have to ensure the VVM use everywhere. The issue raised by Idrissa is worrying in nature. Further classifications and staging of VVM complicates the matters in field. My appeal to Mr.Hans Everts and respected scientists at WHO to come out with VVM and similar tools for other vaccines for uniform adherence to standards in provision of immunization services. Finally, there is another point I want to draw your attention to. VVM reflects only the external cold chain status. We are appreciative of VVM as we are worried about loss of potency of vaccine. VVM is only a indirect indicator of the potency. I would like to know whether there are any studies done to correlate with the stage of VVM and potency of vaccine. I was informed by one of the medical colleges at Bangalore,India who kept Polio vaccines outside a window during summer for 2 days and the VVM never changed from stage 2 onwards. I really do not doubt about VVM, but we should have certain answers to all questions including this. With regards Dr.Giridhara R Babu Future Faculty Programme, PHFI currently at School of Public health, UCLA, Los Angeles -------------------------- As an EPI logistician, I am interested in these discussions. Congratulations to all who have contributed. As for me, I find that VVM makes vaccine management a lot easier, from the planning stage up to service delivery for all strategies (fix, outreach, mobile and mass campaigns). With all these benefits, I can safely say that VVM has contributed to the reduction of vaccine wastage, and shows that with optimum utilization it avoids adverse secondary effects until now Josoa RALAIVAO Specialist Access to Health Services Delivery , SantéNet / USAID Antananarivo Madagascar______________________________________________________________________________ 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:[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 01053E : VVM USE Follow-up on Posts 01028E, 01035E, 01042E and 01050E 14 February 2007 ________________________________________ This posting contains three contributions, from : 1. Vijay Kiran (mailto:vijay@immbasics.org) from India. 2. Hans Everts (mailto:evertsj@who.int) from WHO/ Geneva 3. Idrissa Yalcouyé (mailto:iyalcouye@yahoo.fr) from Haïti who asks an interesting question. ________________________________________ I thank Giridhar Babu to have brought a very useful item to lime light. I agree with Dr. Babu, in that the quality of vaccines from the Govt. Institutions is good and dependable because systems are in place. Immunization from Private practitioners (Including Registered Medical Practioners) in India constitutes about 30% over all, and more so in urban areas. While there is no established system in the private practice for cold chain mantenence, - lack of supervision, lack of giuidelines, lack of regulatory mechanisms may lead to doubting the quality of vaccines administered from private sources. Better late than never, we can start focussing on these issues too. May be a small illustrative hand book on the cold chain, the latest schedule of vaccines would be useful to start with. Dr. Vijay Kiran Country Representative IMMUNIZATIONbasics New Delhi. --------------------- There seems to be a contradiction between "The non availability of refrigerator in most of the places makes it impossible to come out with general guidelines" and "But lack of uniform guidelines, regulation will make it difficult for the optimal utilisation for the community." I do not understand the objection against icepacks. I agree that with VVM we do not need icepacks everywhere, but they still serve a purpose in limiting the degradation of the VVM there where necessary. OPV should be stored at optimal quality everywhere to leave a margin of cold chain flexibility at peripheral level. The peeling off of the lable is often more due to the fact that blocks of ice rather than icepacks are used and can in all cases be prevented by putting the vials in a plastic bag. I think general guidelines can be very useful as long as they do not give standard prescriptive solutions. A general guideline should be based on the same ideas as micro planning for campaigns in that the local conditions play a key role in shaping the solutions. The guideline can help define options for solutions and set standards by which each solution should abide, in this case the status of the VVM. Hans Everts WHO Geneva Technical officer EPI ------------------------------- Hello, I find the discussions and exchanges of ideas on the use of VVM very interesting. I am in perfect agreement with Mr. Giridhara R Babu who requests not to complicate the use of VVM in the field. Nevertheless, I would like to ask a question concerning the various stages of VVM. Here in Haiti, people usually talk of VVM “advanced stage 1â€

Post 01050E : VVM USE Follow-up on Posts 01028E, 01035E and 01042E 5 February 2007 ________________________________________ This posting contains two contributions. The first is from Jedeth Mamora (mailto:jmamora@unicef.org) from Indonesia who asks another question, bringing a new aspect to this discussion. The second is from Giridhara Babu (mailto:giridharbabur@yahoo.com) from India. ________________________________________ Dear Technet, As I understood WHO recommends the use of VVM to measure the effectivity of an antigen, especially polio. There are some events that showed color changes particularly in polio vaccine which often range from yellowish to yellow or reddish to red color. The question is : do we still refer to the VVM despite of the color changes? Some say that if the color changes to certain pH number (ex. 7.6 or above), that vaccine has to be discarded even though the VVM shows good. Is there any research studies to this particular case done before or any similar experiences happened and what is the approach/action taken? Thank you, JJ EPI Asistant Project Officer Health & Nutrition Dept Banda Aceh Zone Office Banda Aceh, Indonesia ------------------------------- Hello everyone, It is an interesting debate here. I was working with polio eradication activities for more than 5 years. In my experience, VVM is very useful in the field but efforts to complicate the process of VVM reading by the field use has to be discouraged. 1. In India and presumably in some of the countries where polio is still a major problem, it is not practical in most of the places to use refrigerator as a stand by for storage. Even if it is done in isolated urban areas, any efforts to endorse this by programme managers would leave the field in confusion. For example, if the vials are kept in refrigerator, how long will the power supply continue, what is the distance from booth to refrigerator, how many people are available in booth for this local transport of vaccine etc. It may also lead in dilution of important efforts like social mobilization done by team members. 2. The non availability of refrigerator in most of the places makes it impossible to come out with general guidelines. 3. Using frozen ice packs for keeping the vial should be strongly discouraged. This is more damaging since the cover gets peeled off and VVM cannot be read. 4. I would not worry much about most of the vaccine used by Government run programmes as at least it contains VVM and most of the workers are aware about reading it before immunizing. My worries are about few private pharma companies manufacturing the polio vaccines that are used by vast majority of Pediatricians in Urban areas of India. I am more worried about their ignorance of VVM and use of refrigerators by most of the Pediatricians to store vaccines. I have personally examined many centers in Bangalore as SMO, WHO-NPSP and found that some of the vials had no VVM and majority of the pediatricians are using refrigerators to store all vaccines. The cold hold over time and lack of uniform temperature adds on to the woes in maintaining good cold chain and this gets complicated by the absence of VVM. Majority of urban kids are immunized by these vaccine, which I think is equivalent to giving sterile water ( and not vaccine). VVM is an effective tool. But lack of uniform guidelines, regulation will make it difficult for the optimal utilisation for the community. With regards Giridhara R Babu Future Faculty Programme of Public Health Foundation of India Currently at UCLA, Los Angeles ______________________________________________________________________________ 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 01042E : VVM USE Follow-up on Posts 01028E and 01035E 19 January 2007 _______________________________________ In reaction to Subhash Choudhury's anecdote on VVM use, five contributions were received, from 1. Anil Varshney (mailto:anilvarshney@yahoo.com) from India 2. Enrique Cuevas (mailto:enricuevas@yahoo.com) 3. Hans Everts (mailto:evertsj@who.int) from WHO/Geneva 4. Henrique Menezes d'Alva (mailto:hdalva@yahoo.com) or (mailto:dalvah@ao.afro.who.int) from WHO/Angola. Henrique also sends two pictures taken during a polio campaign showing VVMs on polio vials. 5. Idrissa Yalcouy (mailto:iyalcouye@yahoo.fr) presently at WHO _______________________________________ Dear Subhash, This practice is perfectly OK, as it secures the vaccines and maintains them at appropriate temperature in a domestic refrigerator. This also has reduced wastages. But this practice is only possible in urban areas and not while the staff goes house to house or in rural areas where refrigerators may not be many. rgds Dr Anil Varshney (Domestic refrigerators are recommended for storage of vaccine with proper precautions) ------------------------- Based in my experience since I have been working with the Polio eradication, I believe this practice is correct respecting two major rules: a) to store the remaining vials separately and well identified b) to use them as a priority in the next vaccination session if VVM did not cross stage II. Again and repeatedly, what is the most important to avoid this practice is; to prepare your session with accurate micro planing, highlighting the target population in order to have the exact amount of doses during the session Enrique Cuevas Former WHO Polio Consultant and Former National EPI Officer at UNICEF in Haiti ------------------------- Referring to the comments by Subhash C Choudhury on India, I think the vaccinators made a wise decision. The advantage of the VVM is not only to passively monitor the cold chain, but at least if not more important, to actually find solutions to problems in operational campaign implementation, beyond simply stopping the vaccination. There is a lot of - undocumented - experience, in particular in the African Region in the use of VVM for polio campaigns: 1) use of non-PIS (PQS) quality vaccine carriers to conduct polio SIA 2) teams not returning to their base for renewal of ice after it has melted and therefore being able to continue vaccination 3) vaccine carriers with only 1 or 2 icepacks, rather than 4, in particular for urban teams 4) teams splitting up at markets and bus stations, while one member keeps the vaccine carrier and the other simply relies on the VVM 5) teams going to remote villages, beyond the cold life of the vaccine carrier 6) teams keeping the vaccine cool by other means, like digging a hole in the ground, keeping it in clay pots, etc.. All these experiences may not be useful or necessary everywhere, but so far Asian countries have taken a much more conservative attitude towards proactive use of VVM as operational planning and implementation tool rather than as a mere monitoring tool. I have seen teams split up on markets taking advantage from the VVM in India, but that is considered an exception to be prevented, rather than the seed of a new operational approach. Applying VVM in a proactive way, including vaccine out of the cold chain, is a change in paradigm from the top-down classical cold chain. Progress is certainly not as much as I would have liked it to be, but I do believe that at least the mental paradigm change has taken place, even though it is only put into practise sporadically. When I did Out of Cold Chain presentations late 20th and beginning 21st century, I risked my life, whereas now, people may still not implement it and be skeptical, but there is an openness that did not exist earlier. Hans Everts WHO Geneva Technical officer EPI ------------------------------------ PHOTOS Dear Mr Choudhury and Technet Colleagues, Many thanks to have shared with us this supposed trouble faced by our colleagues in India. I'll propose to re-check before all the operational conditions of the all cold chain equipments where those OPV vaccines were stored. According our experiences in Angolan EPI activities, and, if those vaccines were well stored as recommended before the campaign it's NO way to find them with all VVMs changed at mi-day, even that under bad weather conditions and in addition with melted Ice pack into vaccine carrier. The problems suppose to be procured at storage conditions of those vaccines before starting the vaccination campaign (see some pictures gotten at end of day in one of Angolan polio NID; campaign was conducted under bad weather conditions with temperature above 35degree C). In other hand I'll propose our Colleagues to use "large cold boxes with frozen ice pack" during the vaccination campaign to support the field vaccinators instead of the practice of using "domestic refrigerator". Have all the best for this new Year 2007. Kindest regards. Eng."Henrique MENEZES D"ALVA EPI Logistician / Vaccine Manager WHO-Angola Luanda-Angola -------------------------------------- Hello Mr. Subhash C Choudhury, bonjour As a field person, I think that there is a need to analyse the positive and negative sides of this initiative taken by the vaccinators in the field to put vaccine vials in a domestic refrigerator located in a commercial booth. Positive side: By putting vaccine vials in a domestic refrigerator, one avoids wastage and it slows down the passage of VVM to stage 3. Negative side: Inside the domestic refrigerator, the vaccines might be in contact with food products or other products that could contaminate the vaccines. We all know that the ideal is to have well frozen icepacks (well conditioned as far as freeze-sensitive vaccines are concerned) to maintain vaccines under good conditions inside the vaccine carrier. But it is a different story altogether in the field due to various reasons. In many countries health centres lack electricity, gas or kerosene to make enough icepacks, above all during mass campaigns. That's why health workers have to resort to intermediate solutions. In conclusion, I'd like to say that if the refrigerator is very clean and does not contain other products likely to contaminate the vaccines, I believe one could use it long enough to vaccinate a few children to avoid ending up with vaccines with VVMs at stage 2 or beyond. But if the refrigerator already contains others products that could contaminate vaccines, it is better not to use it. Mr. Subhash C Choudhury, if some of your colleagues do not agree with this solution, they certainly have their reason. Sincere greetings Mr. Idrissa YALCOUYE, Consultant Vaccines and Cold Chain Management, OPS-WHO Haiti ______________________________________________________________________________ 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 , Canada (http://www.ccisd.org) ______________________________________________________________________________

POST 01035E : VVM USE Follow-up on Post 1028E 5 January 2007 ____________________________________ Following Ãœmit's request for narratives, Subhash Choudhury (mailto:scchoudhury@rediffmail.com) from India submitted the one below and he requests your opinion. ____________________________________ “It is a hot and humid day during Intensified Pulse Polio Immunization. During mid-day the vaccinators find that all the Ice Packs have melted and the VVMs of OPV vials in the Vaccine Carrier are in stage II (this is usually the case when Ice Packs cannot be properly frozen overnight due to insufficient & erratic electric supply). While continuing administration of OPV from one vial, the workers shift remaining vials to a domestic refrigerator available near the Booth. This practice is continued till the end of the day maintaining VVMs do not cross stage IIâ€

POST 01003E : VVM USE AND FREEZE INDICATORS Follow-up on Posts 00960E, 00962E, 00964E, 00970E, 00973E, 00975E, 00978E, 00989E and 00998E 31 October 2006 ___________________________________________ NOTE : Sorry that in POST 01001E, writing too fast, I didn't realize that I had written twchnwt21.org in the first link so it didn't work. I'm sure most of you would have found out... ----------------------------- This message contains a contribution from Søren Spanner (mailto:sspanner@unicef.org) ___________________________________________ As for the control of the temperature in the fridge, ILR and freezer it can be controlled by an electronic thermostat and that is readily available and installed in some appliances. All new equipment should be fitted with an electronic thermostat, that will control the temperature as long as electricity is available. Without electricity there is nothing much to do other than what can be helped with the ice-lining, gen-set or solar power. The thermostats should not be user adjustable. For cold climate areas, it would be useful installing a heating element, controlled by a second thermostat. Because of the manual monitoring (twice per day and usually not in week-ends and holidays) most temperatures outside the specified range are not detected. That means that most of the vaccines that should be discarded are not being discarded, that means a possibility of administration of ineffective vaccines. I have seen lots and lots of cold rooms and freezer rooms without continuous monitoring or alarm systems, that means a possibility administration of ineffective vaccines to regions, districts and PHC level where there is a lot of freezing in ILRs and cold boxes Taking the cost of vaccines and the risk of administration of ineffective vaccines into consideration, it is a must that an effective monitoring system and equipment that is able to maintain the correct temperature be introduced. Soren Soren Spanner, Cold Chain Consultant, Health Section, UNICEF, India Country Office, New Delhi ______________________________________________________________________________ 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) ______________________________________________________________________________