An Evaluation of Cold Chain System for Vaccines in Bangalore. M.K. Sudarshan, M. Sundar, N. G/fish, S. Narendra and Neela G. Patel

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1 Indian J Pediatr 1994; 61 : An Evaluation of Cold Chain System for Vaccines in Bangalore! M.K. Sudarshan, M. Sundar, N. G/fish, S. Narendra and Neela G. Patel Department of Community Medicine, gempegowda Institute of Medical Sciences, Bangalore Abstract. The cold chain plays a major role in the universal immunization programme which helps in preventing against six major killer diseases in children. We collected 144 study samples randomly from different parts of Bangalore to know the training status of personnel, refrigeration facilities, storage, monitoring and potency of vaccines. It was observed that 6.6% of general practitioners were trained under Universal Immunization Programme, monitoring was not satisfactory, and two of the OPV samples from medical practitioners had an unsatisfactory titre dose. Comprehensive orientation/training on cold chain is essential for medical practitioners and other professionals. (Indian J Pedlatr 1994; 61 : ) Key. words : Vaccine; Cold chain; Monitoring; Refrigeration and potency. Global experience with the small pox eradication programme proved to the world that "Immunization was the most powerful and cost effective weapol~ against vaccine preventable diseases. "'1 The six vaccine preventable diseases of childhood were brought to focus in 1985 with the collaboration of World Health Organization and UNICEF as Universal Child Immunization Programme. The vaccines being immunobiological substances, need to be given in a potent form and at the proper age. 2 If the vaccines loose their potency, it cannot be regained and they will no longer protect an individual2 '4 To maintain the potency, a cold chain system for storage and transport of the vaccines, at recommended minimum temperatures, from site of Reprint requests : Dr. M.K. Sudarshan, Professor and Head, Department of Community Medicine, K.I.M.S., V.V. Puram, K.R. Road, Bangalore manufacturer to actual vaccination site was started, s,6 Hence, this study was undertaken to evaluate the cold chain and its logistics in the Bangalore City Corporation area. The objective of this study was to know th6 training status of personnel, refrigeration facility, vaccine storage, monitoring system and the potency of OPV at different levels of cold chain system. (Figure'l'). MATERIAL AND METHODS T]-e study was conducted within the Bangalore City Corporation limits considering each corporation ward as a cluster. As per the recommendation of the World Health Org~ "ization (W.H.C for expanded program of immunization, 30 such clusters were selected at random. Since, no list of general practitioners (GPs') and pharmacists were readily available, two GPs' and two pharmacists were

2 174 THE INDIAN JOURNAL OF PEDIATRICS 1994; Vol. 61. No. 2 1 DIS'rRIC'r STORE Drainpipe Maternity Home, I~alpdOre 1 CORPORATION MATERNITY HOME UFWC, MCH CENTRE J REGIONAL STORE (Publk Health Institute. Baagalore I w"o'- AL'-R I l GENERAL PRACTrI'IONER NUR SING HOME I,,J, i I BENEFICIARY Fi Flow chart of vaccine movement in the city of Bangalore selected (at random) from the geographical centre of the cluster. Hence 60 (2 30) GPs' and 60 (2 x 30) pharmacists were included in the sample population. In addition, 10 nursing homes and 10 maternity homes were included. Further, a wholesale centre, a regional store, a district store and the airport centre were included in the sample, thus amounting to the sample size of 144. (Figure 2). Initially, the personnel of the study centers were interviewed with a pretested proforma, and later'a subsample of 12 cen- ters were selected at random. OPV vial were randomly collected for potency testing and transported to the Pasteur Institute, Coonoor within 56 hrs under strict cold chain maintenance. RESULTS In this study, the majority of study population were general practitioners 60 (41.67%) and pharmacists 60 (41.67%); remaining were nursing homes (6.94%), corporation maternity homes (6.95%) and others (2.78%).

3 1994; Vol. 61. No. 2 THE INDIAN JOURNAL OF PEDIATRK~ 175!,l E] F E E] C C>C >C, GP* PCT NH / I MH WS I ILS DS ] I APT I (~O' ~T ~4 APT Qw~m pm~m~ws. Nunmg~ - A~ Poll Fi Sample Size (144)-Alsonthm lag. lamm~ Home WS. Whm ~lw I~. ~ 1 o m I~ - ~ ~ore. It was observed that only 4 (6.6%) private medical practitioners, 1 (10.0%) of nursing home personnel and 9 (90.0%) of maternity homes personnel were trained under U.I.P. (Universal Immunization Programme). Compared to all the outlets for refrigeration facility, it was observed that 29 (48.3%) private medical practitioners had adequate facility, and in other places it was just satisfactory. Overall, monitoring of cold chain at different places were unsatisfactory, except in maternity homes, district and regional stores. Vaccine stocks were 83.3% and 75% at private medical practitioners, chemists and druggists retailers respectively. As per the W.H.O. guidelines of do's and don'~ for evaluation of cold chain facility, o~iy 10 (6.7%) of GPs' and 2 (3.3%) chemists and druggists scored 'go(xi'. D~scussIoN Quite surprisingly, it was noted that a majority of study population was not trained under U.I.P. (Universal Immunization Programme), and also lacked a formal training in maintaining or handling the vaccines. None of the pharmacists had any training, and even lacked knowledge on

4 176 THE INDIAN JOURNAL OF PEDIATRICS 19q4; Vol. 61. No. 2 TABLE 1. Personnel Training Status, Refrigeration, Monitoring of Vaccines and its Stocks at Different Outlets in Bangalore Category of Training Adequate Monitoring" Satisfactory personnel/level status refrigeration process vaccine facility stocks Airport 0 1 No Not applicable (n = 1) (0.0) (100.6) Regional s~ore 1 1 Yes 1 (n = 1) (100.0) (100.0) (100.0) District store 1 1 Yes 1 (n = 1) (100.0) (100.0) (100.0) Chemist & 0 0 No 1 druggist (Wholesaler) (0.0) (0.0) (100.0) (n = 1) BCC Maternity 9 9 Yes 9 home (90.0) (90.0) (90.0) (n = 10) Nursing home 1 10 No 7 (n = 10) (10.0) (10o.0) (70.0) Private Medical 4 29 No 50 Practitioners (6.6) (48.3) (83.3) (n = 60) Chemists and 0 60 No 45 druggists (0.0) (100.0) (75.0) (Retailers) (n = 6o) + Consists of dial thermometer usage, maintenance of daily twice temperature charts and backup arrangements as per UIP guidelines. cold chaln maintenance. In most of the places, the refrigerator was the only cold chain facility available, concordant with the study by Camachio et al. 7 At some centres, vaccines were stored in refrigerator at the neighbours house, nearby pharmacy or the nursing home which is concordant with the findings of Lee et al. 8 There existed no means of vaccine monitoring in any of the general practitioners, pharmacists or nursing homes. The dial thermometer was not working in some centres and some were showing erratic readings. The maternity home being the nerve centre of vaccination activity, there is a need for emergency measures to be taken up to provide for a proper working environment where deficiencies can be set right at the earliest notice Only 2 of the 60 pharmacists stored OPV. So, randomness in subsampling was lost. Nursing homes and maternity homes gave a satisfactory dose. While, 2 general

5 1994; Vol. 61. No. 2 THE INDIAN JOURNAL OF PEDIATRICS 177 TABLE 2. Results of OPV Testing at Different Levels Levels of Cold Chain No. of OPV samples Tested Satisfactory Airport (n = 1) 0 0 Regional store (n = 1) 1 1 District store (n = 1) 1 1 Chemist & druggist 1 1 wholesaler (n = 1) BCC Maternity home 4 4 (n = 10) Nursin 8 homes (n = 10) 3 3 Private Medical 11 9 Practitioners (n = 60) Chemists & druggists 2 2 (Retailers) (n = 60) To~l practitioners, i.e % showed unsatisfactory samples. CONCLUSION The conclusion we draw from the study are that : (i) The cold chain system was on the whole satisfactory; (ii) Untrained/ignorant manpower is playing a major role in monitoring/ storing and administering vaccines; (iii) Cold chain evaluation/monitoring were unheard of; and (iv) Vaccine procurement/stocks were adequate. RECOMMENDATIONS We recommend the following measuces for improvement. 1. Trained personnel for vaccination activity at all levels. 2. Need for a comprehensive orientation course or programme regarding vaccine storage/maintenance/delivery. To make greater use of multi media in this respect. 3. Strengthen the existing services and monitoring system available at maternity homes, and to make it more efficient and reliable. ACKNOWLEDGEMENT The KSCST, Indian Institute of Science fo~" funding, Director and staff of Pasteur Institute, Coonoor. Dr. Annigeri, Health Officer, Dr. H. Prasanna, Joint Director and Dr. C.R. Krishnamurthy, Additional Director of Health and Family Welfare, Bangalore. REFERENCES 1. Park & Park. Text book of Preventive And Social Medicine, 12th ed. Jabalpur Banarsidas Bhanot Publishers, 1989; pp Government of India, Ministry of Health and Family Welfare, New Delhk.Module- Management of Cold Chain System, Mann et al. Stability of antifertility vaccine consisting of gonadotrophin subunits linked to tetanus-toxoid. Vaccine 1989; 7 (2) : Clinic et al. Field trial of heat stable measles vaccine in Papua New Guinea. ] Trop Med Hyg 1984; 6 : Barrand et al. Reported measles immunization and serological immunity in children attending general practitioners. Aust J Public Health 1991; 15 (2) : Lugosi et al. Transport and storage of vaccines in Hungary-First cold chain

6 17B THE INDIAN JOURNAL OF PEDIATRICS 1994; Vol. 61. No. 2. monitor study in Europe. Bull WHO 1990; 68 (4) : Camachio et al. Evaluation of Cold Chain During Anti-poliomyelitis Vaccination Days. Mexico : Salud Publication, 1990; Lee et al. Support systems facilities and staffing of clinics in Mhala Gazankulu- Are they adequate? South AfMed J 1991; 3 : THE FAMILY-AT THE HE.ART OF HEALTH AND HUMAN DEVELOPMENT From the dawn of human history, the family has been at the heart of human development. The family is the first emotional and social support mechanism we experience, our first teacher, our first health care provider. And it is usually the women in the family who assume responsibility for each of these essential functions. Whether the extended family of several generations living in the same household, the nuclear family of mother, father and their childre9.or the single parent family, what unites them all is love, partnership, a set of common values and a vision of the future. There are contradictions within all family structures. The family can be a shelter, a system of mutual solidarity and support; or it can be restrictive, hindering individual and social development, even providing the setting for child abuse, sexual abuse, battering and homicide. The great challenge for public health is to seek ways to empower families to do well what they do best, and this requires the support of the rest of society. Families are central to human development, but they cannot do the job alone; a positive relationship between families and the health sector is essential. Abstracted from : Tomris Turmen. World Health Nov-Dec 1993; 6 : 3.