Assessing The Knowledge Of Health Workers (Routine Immunization Officers) About Cold Chain System

Medical and Health Science Project and Seminar Material

Chapter One

Introduction

The cold chain is a science, a technology and a process. It is a science since it requires the understanding of the chemical and biological processes linked with perishability. It is a technology since it relies on physical means to insure appropriate temperature conditions along the supply chain. It is a process since a series of tasks must be performed to manufacture, prepare, store, transport and monitor temperature sensitive products. From a geographical perspective, the cold chain has global, regional and local impacts respectively. Global, Specialization enable the distribution of vaccines and other pharmaceutical or biological temperature sensitive products to large facilities.

Agricultural functions permitting the transport of temperature sensitive food products to distant markets. Regional. Can support the specialization of production and economies of scale in distribution. This could involve large cold storage facilities servicing regional grocery markets or specialized laboratories exchanging temperature sensitive components. Local Timely distribution to the final consumer like vaccine to beneficiaries in an immunization session. The cold chain involves the transportation of temperature sensitive products along a supply chain through thermal and refrigerated packaging methods and the logistical planning to protect the integrity of these shipments. (Cyril Chaput PhD 2000) There are several means in which cold chain products can be transported, including refrigerated trucks and railcars, refrigerated cargo ships as well as by air cargo.

“Cold chain” in health care service refers to the process to maintain optimum recommended temperature from the manufacturer, during transportation, storage, and handling of vaccines, starting at the manufacturing and ending with the administration of the vaccine to the client. It is used to help extend and ensure the shelf life of products. The optimum temperature for refrigerated vaccines is between +2°C and +8°C. In addition, protection from light is a necessary condition for some vaccines.

Cold chain and logistics refer to the system of people, policies, procedures, vehicles, fuel, equipment, and technologies that work together to make sure that vaccines given to people are safe and effective. Because most vaccines have specific temperature requirements, an effective cold chain and logistics management system prevents both excessive heat and cold from damaging the vaccines from the time of manufacturing until they are used (WHO Feb.2008).

A decade ago, the vaccines used in most developing countries cost only about one us dollar per child. Today with the addition of combination vaccines against hepatitis b and hemophilia’s influenza type b, and other newly introduced vaccines and increase in the rate per dollar,it now cost as fifteen dollars or more per a fully immunized child (UNICEF 2013).

Background of the Study

Ushongo local government area is one of the 23 local government areas in Benue state which was created in may1989 from Kwande Local Government Area by the then Head of state General Ibrahim Badamosi Babangida. It is located between latitude 70 in the eastern part of Benue state with a total population of 268529 projected from 2006 population census. It bound with Gboko Local Government Area to the North and North-West, Buruku local government area to the north—east, Kwande local government area to the east, Vandeikya local government area to the south and Konshisha Local Government Area to the west. The local government headquarter is Lessel town situated along Gboko-to-Ihugh road, about 135km away from Makurdi her state capital. Her land area is 1228km.2 the postal code of the area is 982. The name of the local government is derived from Ushongo hill located at Ushongo town in Mbayegh council ward.

It is significant to understand that Ushongo local government area was privileged to be a UNICEF assisted local government between 2006 to 2015.within this time it receive tremendous supports from UNICEF, NPHCDA, WHO and BSMH to national program on immunization (NPI). The cold chain system of Ushongo local government was boosted with the capacity of 13 solar and 9 refreegilators.2 in stored in LGA cold store, and one in each comprehensive health center across the eleven council wards in the local government area. This is to serve a total population of children 0-11mths 10742 which constitutes 4% of the total population, children 0-59mths 53706 which constitute 20% of the total population, pregnant women 13426 which is 17% of the total population and women of child bearing age 59068 which constitute 22% of the total population.

Also, considering the high cost of vaccines with the nature of the sensitivity to heat which need to have a smooth and effective cold chain system.Furthermore, NGOs (GAVI), Government at various levels, donor agencies like WHO, UNICEF, stakeholders and all the concern bodies are putting in the best for children health care most especially in term of immunization services. Nevertheless, the cold chain status of Ushongo Local Government Area according to 2018 cold chain inventory out of 14 solar refrigerators, ten (10) are no longer functional, the four (4) are partially functional. Another thing is that shortly after 2015 measles campaign there was an outbreak of measles in four council wards which 47 children within the age range were affected, 32 (68%) with record of been vaccinated with measles but there was no sera conversion which means the vaccine was not potent in 2016. Similarly, 59 children across the local government have BCG failure when post program evaluation was carried out as a result of vaccine failure due to lack of potency as of 2018.

The last stroke that Brock the female camel’s back was the implementation of measles vaccination campaign in December 2017 that was pros ponded and shifted to February 2018 because there was no good and adequate icepacks to implement the program, until icepacks were borrowed from a neighboring local government area. Another problem was that, in August 2018 a WHO consultant on his supervision discovered thousands of doses of different vaccines that has been kept wasted over time due to lack of functional storage facility as said by the routine immunization officer and confirmed by the supervisor.

Statement of the Problem

It is significant to understand that Ushongo local government area was privileged to be a UNICEF assisted local government between 2006 to 2015.withing this time she receive tremendous supports from UNICEF, NPHCDA and BSMH to national program on immunization(NPI). The cold chain system of Ushongo local government was boosted with the capacity of 14 solar and 9 refreegilators. Two in LGA cold store and one in each comprehensive health center across the eleven council wards in the local government area.

This is to serve a total population of children 9-59mths 10952 as of 2015 out of this there was an outbreak of measles in four council wards which 47 children within the age range of 9-59mths were affected, 32 (68%) with record of been vaccinated with measles but there was no sera convection which means the vaccine was not potent. Similarly, in 2016, out of 11234 children of 0 – 59months, 59 children of 0-11mthsacross the local government have BCG failure when post program evaluation was carried out as a result of vaccine failure and lack of potency. In 2018,11516 the last stroke that Brock the camel’s was the implementation of measles vaccination campaign in December 2017 that was proponed and shifted to February 2018 because there was no good and adequate icepacks to implement the program, until icepacks were borrowed from a neighboring local government area.

Another problem was that, in August 2018 a WHO consultant on his supervision discovered thousands of doses of different vaccines that has been kept wasted over time due to lack of functional storage facility as said by the routine immunization officer and confirmed by the supervisor. It was unfortunate to discover that, out of 14 solar refrigerators, only 4 are partially functional including the most recently installed ones. This burden is adversely affecting a large population of children between 0 to 59mounths (53706) who are leaders of tomorrow and pregnant women who may be legible for various schedules of immunization. These amounted to vaccine wastage and shortage resulting to missed opportunity.

Also children receiving vaccines that cannot protect them as intended but rather be making children sick. Thus, drown the attention of the researcher to carry out study to assess the responsible factors. There is a need to ensure that an effective product is being used. Vaccine failures caused by administration of compromised vaccine may result in the re-emergence or occurrence of vaccine preventable disease. Careful management of resources is important. Vaccines are expensive and can be in short supply. Loss of vaccines may result in the cancellation of immunization clinics resulting in lost opportunities to immunize.

Revaccination of people who have received an ineffective vaccine is professionally uncomfortable and may cause a loss of public confidence in vaccines and/or the health care system.

Objectives of the Study

To assess the knowledge of health workers (routine immunization officers) about cold chain system in Ushongo local government area.
Identify both the general and local factors affecting effective cold chain system in Ushongo Local Government Area of Benue State.
To identify the adverse effects of ineffective cold chain system to communities in Ushongo Local Government Area of Benue State.
To assess the level of importance attached, and commitment and support giving to cold chain system by the Ushongo local government council to ensure effective and sustainable cold chain system in Ushongo Local Government Area of Benue State.
To identify the availability and function ability of cold chain logistics in Ushongo Local Government Area.

Research Questions

Do health workers of Ushongo local government (routine immunization officers) have knowledge on cold chain system and logistics?
Are there general and local factors affecting cold chain system in Ushongo Local Government?
What are the related problems that broken chain or ineffective cold chain system cause to the community and Ushongo Local Government?
How would Ushongo local government council show support and concern to cold chain system for ensuring effective and sustainable cold chain system and logistics?
Are there remedies for broken cold chain system in Ushongo local government area?

Significance of the Study

The finding of this study will help health workers (routine immunization officers) in Ushongo local government to be aware of the factors affecting effective cold chain system, and also recognize solutions that can help in addressing the identified problems.

The findings of this study will also be of help to any person that may wish to carry a further research study on this very topic, the donor organizations, stakeholders in the health system.

The findings of this study will help the management of Ushongo Local Government Council to understand the problems of ineffective cold chain system to the communities in the area.

The findings of this study will also help the management of Ushongo Local Government Council to know her responsibility for ensuring an effective cold chain system and breaching the gap between the effective cold chain and ineffective cold chain system.

Delimitation of the Study

This study is limited to Ushongo Local Government Area. It is also limited to 55 health workers in Ushongo Local Government Area (53 routine immunization officers (RIO) in health facilities offering immunization services both privates and publics, one cold chain officer CCO and onelocal immunization officer (LIO). It is also limited to assessment of factors affecting cold chain system in Ushongo local government area, Benue State.

Chapter Five

Discussion, Conclusion and Recommendation

Discussion

More females participated in this study than males, this is expected as majority of the health workers that work in Immunization Centres are nurses and nursing is dominated by women. Majority of the respondents are between the ages of 40 – 44years. This represents a population that is still very active in the population and gave responses that represented what exists in the centres.

Knowledge of the storage of vaccine by health workers can be said to be good with average percentage score of 64.5%. only 45 out of 141 respondents could identify OPV as the most heat sensitive, 70 out of 141 could identify DPT as the most sensitive to freezing, 126 out of 141 could cite the appropriate temperature range for vaccine storage, this contradicts the fact that most of them were graduates and should have good knowledge of vaccine storage and handling practices. The poor knowledge for example about the effect of freezing DPT vaccine potentially adversely will affect the quality of the administered vaccine, opening spaces for epidemics due to vaccine preventable diseases like poliomyelitis. This corroborates the findings of Thakker and Woods28 where only 16 out of 40 respondents were aware of the appropriate storage conditions for the vaccines. It is also in line with the study done in Los Angeles where only 16% of vaccine storage coordinators could cite appropriate temperature forvaccine5.

All vaccines should be stored and handled under recommended condition to ensure optimal protection from vaccine preventable disease when they are administered. Where health workers in charge of vaccine at the Immunization centres lack proper knowledge of vaccines to rage and handling there is every tendency that the vaccines under their care will not be properly stored and handled.

Majority of the respondents are trained for the job as most of them have undergone both pre-service training and in-service training however this contradicts the fact that they have fair knowledge of vaccine storage and handling practices despite the training they received. This is in disagreement with the findings of Berhaine and Demissie31 where majority of the centres had neither trained personnel nor budget for the maintenance of the cold chain. It also disagreed with the findings of the study done by the Federal Ministry of Health where the result of that survey showed that poor staff training was one of the factors responsible for cold chain problems in Nigeria.34
The national guidelines recommended that vaccines received are immediately placed under the required storage conditions and that a nominated trained person should be able to work a written procedure developed to meet local needs and that temperature of the refrigerator should be monitored with a maximum and minimum thermometer and that the maximum and minimum temperature should be recorded regularly.

Most of the centres do not receive funds for equipment repairs and cold chain maintenance and cannot maintain their equipment or replace damaged ones. Those that received funds receive between N50,000 – N200,000 yearly which is not enough to maintain the cold chain and repair equipment.

Provision of adequate equipment and implementation of a properly designed monitoring and control system are important components of asuccessfulimmunizationprogramme.Mostofthecentresvisiteddonothave refrigerators at all while in some centres, refrigerators were available but were not functional. Majority of the centres do not have maximum and minimum thermometer and those who have were not making use of it. Regular maintenance of temperature charts is an effective way of monitoring the functioning of refrigerators. This helps in initiation of timely action in case of a break down by indicating time and diversion of temperature faltering but from this study most of the centres do not keep their charts and cannot detect when the temperature goes outside the recommended range.

In one of the centres when asked to show the maximum and minimum thermometer the person brought “clinical thermometer” these findings are in line with the study done by Grasso in Italy when it was discovered that out of the 52 primary vaccination centres visited and inspected none of the seven main office selected for monitoring had maximum and minimum thermometer and none monitored the Internal temperature of the refrigerator.46
The use of maximum and minimum thermometer guarantee vaccine potency and the success of immunization, when it is not available at immunization centers that means such centres do not monitor their refrigerator temperatures and as such, the cold chain can easily be interrupted.

In 6 (22.2 %) of the centers visited generators were available but not functional while 10 (37.0%) of the facilities do not have generators at all, some center also lack vaccine stock control books and vaccine carriers. In all those centers where all these equipments are lacking shows poor adherence to national guidelines for vaccine storage.
Also in this study, vaccine storage were found to be defective in some centers, some centers stored vaccines and vaccine diluents on the refrigerator door shelves while in some centres vaccine were stored along with sachet water and soft drinks. Ideally, the fridge containing vaccines should not be used to store other products.

However in this study vaccines were sharing spaces with sachet water and drinks and consequently it was difficult to maintain the required temperature ranges. Also storage of foods and drinks in vaccine refrigerators must mean that refrigerators were opened frequently and that both the code of practice for storing vaccines and the food hygiene regulation were broken. It also implied that refrigerators were opened frequently and exposure of vaccines at ambient temperatures and hence the temperature can easily go outside the recommended range. This is in line with the study done by Pabst and Taylor36 where the cold chain personnel used the refrigerator to cool freshly made tea. It is also in line with the study done by Berhaine and Demissie31 where storage of vaccine in the refrigerator was not proper in 47 (73.4%) of the centers. It was also observed that reconstituted vaccines were kept on thawed ice packs or left on the tables and exposed to the ambient temperature at the time of their administration. This corroborates with the study done by Goel30 in India, where cold chain sickness were attributed to exposure of vaccines to atmospheric temperature, keeping the vaccine vial in hand or pocket.

Another issue of serious concern is power supply. Some of the centres visited do not have a standby generator incase of power outage. Electrical power or an alternate source of energy is crucial to the maintenance of the cold chain. This is compounded by the fact that only 40.8% of these primary/community health centres have a functional generator that can help maintain the cold chain. Given these findings, solar refrigerator needs to be given to the health centres to ensure that the cold chain is maintained at every point in time. Results of the cross tabulation between in-service training and knowledge of vaccine storage and handling shows that in-service training has a positive impact on the knowledge of vaccine storage and handling by the health workers, this implies that giving them training from time to time will help improve their knowledge of vaccine storage and handling.

This study also showed that the vaccine vial monitors (VVM) of oral polio vaccines picked at random and checked for the stage of VVM colour change showed that they are still within the normal colour change as all of them were still between stage I and stage 2. But this is inadequate because VVM does not tell us if the vaccine has lost potency ornot.

Conclusion and Recommendation

Personnel training were generally good and majority of the health workers that work in immunization centers are nurses, knowledge of vaccine storage and handling by health workers were generally good. However equipments were found lacking in some health facilities and in some where they are available they were not functional. All the OPV checked for VVM colour change were found to be within normal range. The result of the cross tabulation showed that giving in service training to the health workers will help improve their knowledge of vaccine storage andhandling.

In all, the quality of vaccine cold chain in twenty seven health facilities visited were generally good but efforts need to be directed at the availability of equipments and maintenance. Also vaccine handling practices need to be looked into, as some of the health workers have poor vaccine handling practices.

Recommendations

Faulty cold chain equipment should be repaired without delay by providing adequate fund to the centres.
Health workers that work in immunization centers should be given in service training from time to time.

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