IN-DEPTH ANALYSIS OF COLD CHAIN, VACCINE SUPPLY AND LOGISTICS MANAGEMENT FOR ROUTINE IMMUNIZATION IN THREE INDIAN STATES: AN INCLEN PROGRAM EVALUATION NETWORK STUDY By Central Coordinating Office The INCLEN Trust International F1/5, Okhla Industrial Area, Phase I, New Delhi-110020, INDIA Supported by Ministry of Health and Family Welfare, Government of India Departments of Health and Family Welfare (Bihar, Gujarat and Kerala) And Bill and Melinda Gates Foundation 1 Table of contents Table of contents ........................................................................................................................................... 2 Abbreviations ................................................................................................................................................ 5 1. Background and rationale ..................................................................................................................... 6 1.1 The Current UIP .................................................................................................................................. 6 1.2 Current Cold Chain System in India and States .............................................................................. 8 1.3 Vaccine and Immunization Logistics Chain ................................................................................... 8 1.4 Type of Equipments/ Devices ....................................................................................................... 10 1.5 Cold Chain Manpower and Training System ................................................................................ 11 1.6 The Indenting and Storage Norms ................................................................................................ 12 1.7 Prospects for New Vaccine Introduction ...................................................................................... 13 1.8 Vaccine Specific Cold Chain Requirements ................................................................................. 14 1.9 Storage and Transport Volume per Dose ...................................................................................... 16 1.10 Volume per Each Fully Immunized Child .................................................................................. 18 1.11 Open Vial Policy ......................................................................................................................... 18 1.12 National Cold Chain Management Information System ............................................................. 19 2. The Current Assessment ..................................................................................................................... 20 2.1. Rationale ......................................................................................................................................... 20 2.2. Goal and Objectives of the Study ................................................................................................... 20 3. Study Methodology ............................................................................................................................. 21 3.1. Study Design ................................................................................................................................... 21 3.2 Study area ........................................................................................................................................ 21 3.3 Study Implementation ................................................................................................................. 22 3.3.1 Central Coordinating Team & Central Coordinating Office ................................................... 22 3.3.2 State Coordinating Center & Partner Medical Colleges ..................................................... 23 3.3.3 Study Tool Development and Finalization ......................................................................... 23 3.3.4 Training of the Research Teams ......................................................................................... 24 3.3.5 Data Collection ................................................................................................................... 25 3.3.6 Quality Assurance ............................................................................................................... 25 3.3.7 Assumptions and Context for Analysis of the Data ................................................................ 27 Findings ...................................................................................................................................................... 28 2 4. Magnitude of data collected ................................................................................................................ 28 5. Vaccine supply network organization in the study states ................................................................... 28 6. Cold chain inventory ........................................................................................................................... 32 6.1. Inventory of electrically powered cold chain equipments .............................................................. 32 6.2. Age of the electrically powered cold chain devices ........................................................................ 34 6.3. Coolant types of the cold chain devices .......................................................................................... 35 6.4 Devices to be boarded Off .............................................................................................................. 36 7 Equipment Maintenance ..................................................................................................................... 36 7.1 Voltage Stabilizers .......................................................................................................................... 36 7.2 Sickness Rate .................................................................................................................................. 37 7.3 Breakdown maintenance practices and sickness rates ............................................................ 39 7.4 Preventive maintenance practices ........................................................................................... 39 8 Vaccine safety and temperature integrity ............................................................................................ 40 8.1 Temperature Monitoring Practice ................................................................................................... 40 8.2 Vaccine storage practices ................................................................................................................ 41 8.3 Temperature records by the LogTag devices .................................................................................. 41 8.4 Temperature Monitoring by LogTag Devices ................................................................................. 42 8.5 VVM and freezing status of vials at outreach sites ......................................................................... 45 8.6 Temperature maintenance during vaccine transfer between facilities ............................................ 45 8.7 Temperature maintenance during vaccine transfer to outreach sessions ........................................ 46 9 Infrastructure ....................................................................................................................................... 47 9.1 Building of the facilities .................................................................................................................. 47 9.2 Dry supply storage .......................................................................................................................... 47 9.3 Electricity supply ............................................................................................................................ 47 9.4 Manpower availability .................................................................................................................... 48 10 Vaccine supply and logistics ........................................................................................................... 49 10.1 Vaccine supply network and practices ............................................................................................ 49 10.2 Forecasting, indenting and supply of vaccines ............................................................................... 49 10.3 Stock record keeping ....................................................................................................................... 50 10.4 Stock out of vaccines ...................................................................................................................... 50 11 Cold chain space ............................................................................................................................. 52 11.1 Currently available +20C to + 80C space and projection for new vaccine addition ........................ 52 3 11.2 Currently available -150C to -250C space and projection for new vaccine addition ....................... 57 12 Recommendations ........................................................................................................................... 59 Annexure ..................................................................................................................................................... 61 Investigating Team Members.....................................................................................................................