Is freezing in the vaccine cold chain an ongoing issue? A literature review

Water-Soluble and Freezable Aluminum Salt Vaccine Adjuvant

Particulate aluminum salts have long occupied a central place worldwide as inexpensive immunostimulatory adjuvants that enable induction of protective immunity for vaccines. Despite their huge benefits and safety, the particulate structures of aluminum salts require transportation and storage at temperatures between 2 °C and 8 °C, and they all have exquisite sensitivity to damage caused by freezing. Here, we propose to solve the critical freezing vulnerability of particulate aluminum salt adjuvants by introducing soluble aluminum salts as adjuvants. The solubility properties of fresh and frozen aluminum chloride and aluminum triacetate, each buffered optimally with sodium acetate, were demonstrated with visual observations and with UV-vis scattering analyses. Two proteins, A244 gp120 and CRM197, adjuvanted either with soluble aluminum chloride or soluble aluminum triacetate, each buffered by sodium acetate at pH 6.5-7.4, elicited murine immune responses that were equivalent to those obtained with Alhydrogel®, a commercial particulate aluminum hydroxide adjuvant. The discovery of the adjuvanticity of soluble aluminum salts might require the creation of a new adjuvant mechanism for aluminum salts in general. However, soluble aluminum salts might provide a practical substitute for particulate aluminum salts as vaccine adjuvants, thereby avoiding the risk of inactivation of vaccines due to accidental freezing of aluminum salt particles.

Identification of film-based formulations that move mRNA lipid nanoparticles out of the freezer

COVID-19 vaccines consisting of mRNA lipid nanoparticles (LNPs) encoding the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike protein antigen protected millions of people from severe disease; however, they must be stored frozen prior to use. The objective of this study was to evaluate the compatibility and stability of mRNA LNPs within a polymer-based film matrix. An optimized formulation of polymer base, glycerol, surfactants, and PEGylated lipid that prevents damage to the LNP due to physical changes during the film-forming process (osmotic stress, surface tension, spatial stress, and water loss) was identified. Surfactants added to LNP stock prior to mixing with other film components contributed to this effect. Formulations prepared at pH ≥ 8.5 extended transfection efficiency beyond 4 weeks at 4°C when combined with known nucleic acid stabilizers. mRNA LNPs were most stable in films when manufactured in an environment of ∼50% relative humidity. The optimized formulation offers 16-week stability at 4°C.

Using freeze-preventive cold boxes in rural Nepal: A study of equipment performance, acceptability, system fit, and cost

We conducted a field evaluation using qualitative and quantitative methods to assess freeze prevention of vaccines transported and stored in a recently developed, World Health Organization-prequalified freeze-preventive cold box (FPCB) as compared to currently used standard cold boxes (SCBs). The study assessed the FPCB's practical use, health worker acceptance, health system fit (including cost considerations), and challenges faced by health workers in variable conditions and geographical settings. The evaluation took place in five health facilities across hilly and plains districts of Nepal in two phases: Phase 1 involved FPCBs in simulated use alongside SCBs. In Phase 2, actual vaccines were used in the FPCBs. The study gathered quantitative data from logbooks and electronic temperature monitors placed inside and outside the cold boxes. Qualitative data were collected from health workers, cold chain personnel, and immunization program managers involved in the vaccine cold chain at multiple levels. No damage, durability issues, or freezing incidents were observed when using FPCBs, but two incidents of freezing occurred when using SCBs. FPCBs also took longer to cool down than SCBs. Participants mostly found the FPCB to be safe and user friendly for vaccine transportation and short-term storage. Advantages of the FPCB as compared to the SCB include its ability to minimize vaccine wastage, to keep freeze-sensitive vaccines safe (the average value of freeze-sensitive vaccines transported per shipment was $1,704), and to ease preparation through elimination of the need to condition ice packs. Procurement price ranges for FPCBs overlap those for SCBs. Disadvantages of the FPCB include its greater size and weight, which require more personnel and vehicles during transportation. This suggests that lighter and smaller FPCBs would be more effective and acceptable for the Nepal immunization program and other, similar immunization programs conducted globally.

Effectiveness of the online-eLearning program KeepCoool at improving the vaccine cold chain in general practices

BACKGROUND

Protecting vaccines from freeze damage is a poorly addressed problem. We describe the effectiveness of the eLearning KeepCoool on cold chain maintenance in general practices.

METHODS

For this intervention study, temperatures of vaccine refrigerators were logged at one-minute intervals. Personnel from practices with cold chain breaches was offered the eLearning. The primary outcome was the intervention's effectiveness to achieve temperatures in the target range (2 to 8°C) in the sixth week (follow-up) compared to the first (baseline). Using continuous temperature data, a generalized additive model for location, scale and shape was estimated.

RESULTS

The practice response rate was 38% (64 of 168). At baseline, 73% of the practices and 68% of the refrigerators (51 of 75) showed cold chain breaches. 47% of the practices (n = 22 with 24 refrigerators) participated in the eLearning (55 physicians and practice assistants). At follow-up, 17% of those refrigerators were in the target range continuously, 38% reached targets 95% of the time while always >0°C, and temperatures ≤0°C decreased by 63%. Based on 2 million temperature data, the average Euclidian distance based on regression showed a significant improvement (p<0.05).

CONCLUSION

The eLearning KeepCoool improved the practices´ vaccine cold chain. It is freely available at https://keepcoool.ukbonn.de.

A cross-sectional assessment of the effects of select training modalities on vaccine cold chain management

Background

Vaccines offer arguably the most cost-effective public health intervention. Vaccine supply chain management which is a critical building block faces many Human resources challenges mainly due to the special attributes of vaccines.

Objective

This study attempted to measure the effect of training on vaccine cold chain handler knowledge and practices.

Methods

A cross-sectional research design, using predominantly quantitative data collection techniques, was used. Facilities that have offered vaccination services for more than a year and report through the HMIS system were eligible for selection. Observation checklists and structured questionnaires were used. SPSS was used to analyse data.

Results

Vaccine cold chain management among the study group had an average score of 65.33% range (31-85%). The average knowledge score among the study respondents was 62.42% with a range (45-95%). The knowledge of respondents generally increases with an additional increase in the number of training modalities.

Conclusions

The status of VCCM is at about 65.33% below the target of 80% set by the EVM. The trainings have an effect on both knowledge of handlers and their practice especially when deployed in a multi-pronged design and thus these trainings need to be aligned to achieve synergy.

ABBREVIATIONS

CCE, Cold Chain Equipment; DHIS2, District Health Information Systems 2; DHO, District Health Officer; DPT, Diphtheria, Pertussis, Tetanus; DVS, District Vaccine Stores; EPI, Expanded Program for Immunisation; EVM, Effective Vaccine Management; FEFO, First Expiry First Out; GAVI, Global Alliance for Vaccines and Immunisation; HMIS, Health Information Management Systems; IRC, International Rescue Committee; KII, Key Informant Interview; LIAT, logistics indicator assessment tool; PATH, Program for Appropriate Technology in Health; PHC, Primary Health Care; QPPU, Quantification and Planning and Procurement Unit; SOPs, Standard Operating Procedures; SPSS, Statistical Package for Social Sciences; UNEPI, Uganda National Expanded Program for Immunisation; UNICEF, United Nations Children's Fund; VPD, Vaccine Preventable Diseases; VVM, Vaccine Vial Monitors; WHO, World Health Organisation.

Health professionals' knowledge on vaccine cold chain management and associated factors in Ethiopia: Systematic review and meta-analysis

BACKGROUND

Vaccines are playing a great role in prevention of many infectious diseases worldwide. Health professionals' knowledge towards vaccine cold chain management is an essential element of maintaining vaccine's potency at shelf and during transportation. Studies on health professionals' knowledge on vaccine cold chain management system and associated factors in Ethiopia have inconclusive findings. This systematic review and meta-analysis is aimed to produce the overall level of health professionals' knowledge on vaccine cold chain management system and to identify its associated factors in Ethiopia.

METHODS

Systematic review and meta-analysis was conducted on health professionals' knowledge on vaccine cold chain management in Ethiopia. It is registered under PROSPERO website with registration number CRD42023391627. Literature search was made on international data bases using medical subject heading and key words. Data were extracted using Microsoft excel and imported to STATA version 17 for analysis. Heterogeneity was checked using Cochrane Q test and I2 statistics. Weighted Inverse variance random effect model was used to estimate the pooled level of health professionals' knowledge on vaccine cold chain management. Publication bias was checked using funnel plot and using Egger's test.

RESULTS

A total of nine studies were included in the review. The pooled health professionals' good knowledge on vaccine cold chain management in Ethiopia is 49.92% with 95% CI (48.06-51.79). Having five years or more experience AOR 2.27 95% CI (1.72-2.99), being nurse AOR 3.03 95% CI (1.47-6.27), received on job training AOR 6.64 95% CI (4.60-9.57), EPI guideline available at facility AOR 2.46 95% CI (1.75.-3.48) are factors positively associated with health professionals' knowledge on vaccine cold chain management in Ethiopia.

CONCLUSION

The pooled prevalence of good knowledge on vaccine cold chain management among health professionals is much lower than the expected level. There is a need to plan on job trainings for all vaccine handlers and other health professionals supposed to work on vaccination program.

[Clinical Practice Guidelines for Vaccine Management in Ambulatory Care: a Systematic Review Following the AGREE II Approach]

BACKGROUND

Breaches in the cooling chain with exposure of vaccines to temperatures outside the target range of +2°C to +8°C may reduce their efficacy and impair immune responses. Following the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach, this review assesses the quality and content of international clinical practice guidelines on vaccine management. The results were used to derive recommendations for the vaccine management in ambulatory care in Germany.

METHODS

Based on a systematic search and screening process with predefined criteria, the selected guidelines were rated by three reviewers using the AGREE II domains: scope and purpose, stake-holder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. The content of the guidelines was retrieved and summarized according to five predefined categories: cold chain, responsibilities, equipment, storage, and monitoring. The review was registered in PROSPERO (CRD42021270524).

RESULTS

A total of nine clinical practice guidelines were selected for evaluation. The sum score of the documents varied between 17% to 89% of the maximum possible score. All guidelines included recommendations in the five content categories but differed in detail. The key recommendations were: a) continuous cold chain required; b)≥2 trained, responsible staff members; c) storage in original wrappings; d) appropriate, preferably purpose-built refrigerator with two-point thermometer or data logger; e) routinely implemented monitoring processes including daily temperature recording. A public monitoring system was recommended in some guidelines.

CONCLUSION

Our systematic review identified key information for vaccine storage and management to support the future development of German recommendations for vaccine storage.

Micro- and nanosystems for the detection of hemorrhagic fever viruses

Hemorrhagic fever viruses (HFVs) are virulent pathogens that can cause severe and often fatal illnesses in humans. Timely and accurate detection of HFVs is critical for effective disease management and prevention. In recent years, micro- and nano-technologies have emerged as promising approaches for the detection of HFVs. This paper provides an overview of the current state-of-the-art systems for micro- and nano-scale approaches to detect HFVs. It covers various aspects of these technologies, including the principles behind their sensing assays, as well as the different types of diagnostic strategies that have been developed. This paper also explores future possibilities of employing micro- and nano-systems for the development of HFV diagnostic tools that meet the practical demands of clinical settings.

Photonic Crystal Sensor Evaluating the Effectiveness of Medical Products under Different Storage Conditions

The effectiveness of time- and temperature-sensitive medical products (TTSMPs) (vaccines, medicines, and biological agents) is generally evaluated by sporadically checking the storage conditions recorded in electronic thermometers. However, electronic thermometers do not achieve all-time and all-regional record, resulting in the wrong evaluation of a single TTSMP and seriously endangering public health. Herein, we report a photonic crystal sensor for evaluating the effectiveness of a single TTSMP processing storage environment. The photonic crystal sensor assembled by colloidal microspheres (WO3-x nanospheres were added into the microsphere gap) generates a fascinating composite color of angle-dependent structural color (maximum reflectivity = 45%) and durative color (WO3-x coloration). Effectiveness evaluation principle reveals that the pattern on the sensor, which was printed by the composite color, fades sensitively to time and temperature, thus having different visible periods (0-21 days affected by temperature). The visible periods of the patterns can be used to evaluate a single TTSMP's effectiveness stored under different temperatures. Furthermore, the photonic crystal sensor shows outstanding flexibility and slight adhesion, offering a promising application toward the effectiveness evaluation of TTSMPs throughout storage, transportation, and sales processes.

Vaccine cold chain management practice and associated factors among health professionals in Ethiopia: systematic review and meta-analysis

BACKGROUND

Administration of potent vaccine in a manner of well-maintained cold chain system is one of the public health focus areas in developing regions of the world. Health professionals' adherence towards good vaccine cold chain management practices is an important element to ensure potent vaccine reached to users. Studies on health professionals' practice on vaccine cold chain maintenance and associated factors in Ethiopia have shown wide variations. The aim of this systematic review and meta-analysis is to produce the overall/pooled prevalence of health professionals' good vaccine cold chain management practice and to identify its associated factors in Ethiopia.

METHODS

Systematic review and meta-analysis was conducted on vaccine cold chain management practice and associated factors among health professionals in Ethiopia. Literature search was made on international data bases using medical subject heading and key words. Data were extracted using Microsoft excel and imported to STATA version 17 for analysis. Heterogeneity was checked using Cochrane Q test and I² statistics. Weighted inverse variance random effect model was used to estimate the pooled level of good vaccine cold chain management practice among health professionals. Publication bias was checked using funnel plot and using Egger's test.

RESULTS

A total of ten studies were included in the review. The overall/pooled prevalence of good vaccine cold chain management practice in Ethiopia is 27.48% with 95% CI (25.70-29.26). Having good knowledge on vaccine cold chain management AOR 2.27 95% CI (1.72-2.99), and have received on-job training AOR 6.64 95% CI (4.60-9.57) are factors positively associated with vaccine cold chain management practice among health professionals in Ethiopia.

CONCLUSION

The overall/pooled prevalence of good vaccine cold chain management practice is much lower than the expected level. There is a need to plan on-job trainings for all vaccine handlers and other health professionals supposed to work on vaccination program.

Understanding and preventing vaccination errors

INTRODUCTION

Vaccine-related medication errors can occur at each step of the vaccination process: prescribing, dispensing, preparation, administration, monitoring, transport, and storage. We aimed to describe current knowledge of vaccination-related errors to identify areas for improvement.

MATERIAL AND METHODS

We performed a literature review on PubMed, using MeSH terms, from 1998 to 2020 to identify articles that would illustrate vaccine-related medication errors. We developed a questionnaire for health professionals concerning prescribing, dispensing, or administering vaccines via Facebook, and then identified priority areas for information to reduce vaccine-related medication errors.

RESULTS

A total of 227 answers were collected from midwives (N = 90), pharmacists or technicians (N = 75), and physicians or interns (N = 62). Practitioners gave wrong answers on live vaccines administered during pregnancy (>10 % of physicians), incorrect acronyms for the DTCaP (diphtheria, tetanus, pertussis, poliomyelitis) vaccine corresponding to branded products (72 % of midwives), lack of marketing authorization knowledge for the influenza vaccine (46 %), duration of vaccine conservation outside of the refrigerator (52 %), or intravenous administration of the rotavirus vaccine (23 %). Most health professionals mentioned the possibility of writing procedures for the various steps of the vaccine process, but only few of them have actually done it (15 % for dispensing/administration versus 61 % for storage). Ten key points for initial or ongoing training of health professionals have been summarized.

CONCLUSION

There is partial mastery of vaccine knowledge among health professionals. Our final table presents the most important elements of these results for educating health professionals on potential vaccine-related medication errors.

Capsule-based colorimetric temperature monitoring system for customizable cold chain management

The COVID-19 pandemic and the resulting supply chain disruption have rekindled crucial needs for safe storage and transportation of essential items. Despite recent advances, existing temperature monitoring technologies for cold chain management fall short in reliability, cost, and flexibility toward customized cold chain management for various products with different required temperature. In this work, we report a novel capsule-based colorimetric temperature monitoring system with precise and readily tunable temperature ranges. Triple emulsion drop-based microfluidic technique enables rapid production of monodisperse microcapsules with an interstitial phase-change oil (PCO) layer with precise control over its dimension and composition. Liquid-solid phase transition of the PCO layer below its freezing point triggers the release of the encapsulated payload yielding drastic change in color, allowing user-friendly visual monitoring in a highly sensitive manner. Simple tuning of the PCO layer's compositions can further broaden the temperature range in a precisely controlled manner. The proposed simple scheme can readily be formulated to detect both temperature rise in the frozen environment and freeze detection as well as multiple temperature monitoring. Combined, these results support a significant step forward for the development of customizable colorimetric monitoring of a broad range of temperatures with precision.

Impact of Improper Storage of ChAdOx1-S (AstraZeneca) Vaccine on Its Efficacy and Safety

Background: In May 2021, there was an incident regarding giving patients AstraZeneca vaccines stored improperly. They were stored at room temperature (21 degrees centigrade) for 18 h, 12 h longer than the producer recommends. Aim of the study: The paper aims to contribute to the body of knowledge concerning the efficacy and safety of the ChAdOx1-S (AstraZeneca) vaccine concerning the requirements for cold supply chain specification. Patients and methods: Improperly stored vaccines were given to 44 patients, and 39 of them decided to take part in the study. The Control group consisted of 56 people vaccinated on the same days by the same medical teams, using properly stored medicines. Results: The concentration of anti-S1 SARS-CoV-2 Spike protein IgG antibodies did not differ significantly between the groups. Examined group median 70 kU/L (20;100). Control group median 66 kU/L (32.75;100), p = 0.751. We did not observe any COVID-19 infections in either the control or examined group for half a year after the incident. People from each group reported that local and systemic adverse events occurred directly after the first and second doses. In the control group, one case of spontaneously subsiding face edema and joint pain was observed. There were no severe or fatal adverse events. There were no significant differences between the groups, besides the fatigue, after the second dose. Conclusion: AstraZeneca vaccine ChAdOx1-S stored at 21 degrees centigrade for 18 h before vaccination has the same safety profile (p < 0.05) and the same efficacy (p < 0.05) as the vaccines stored in conditions recommended by the producer.

Adherence to WHO vaccine storage codes and vaccine cold chain management practices at primary healthcare facilities in Dalocha District of Silt'e Zone, Ethiopia

Background

The main elements of effective vaccine cold chain management at the immunization service delivery point are well-trained vaccine cold chain handlers, vaccine storage equipment, and appropriate vaccine management procedures. Vaccine cold chain handlers must have enough expertise to provide the correct vaccine at the right time, maintain vaccine potency, and minimize vaccination failures. The study assessed knowledge of vaccine cold chain handlers on vaccine cold chain management, adherence to the WHO vaccine storage codes and vaccine cold chain management practice at primary health facilities in Dalocha district of Silt'e zone.

Method

Institutional-based cross-sectional study was done at twenty-eight primary health facilities. One hundred forty primary health workers were drawn from four health centers and twenty-four health posts operating in Dalocha woreda of Silt'e zone, SNNPR, Ethiopia. A self-administered questionnaires and on-spot observation checklists were adapted from the WHO and WHO-UNICEF-effective vaccine management assessment tools to collect data from cold chain unit of the primary healthcare facilities. Data were entered to EPI data version 3.1; exported and analyzed using SPSS version 22. Statistical analysis was carried out to determine the level of knowledge, adherence to WHO cold chain management guideline and vaccine handling practice. The relationship that the knowledge of primary healthcare workers, primary healthcare workers training status, primary healthcare facilities' adherence to WHO vaccine storage codes, and length of work experience of primary health care workers have with the vaccine management practice were also explored

Result

Above Half (54%) of the respondents have satisfactory knowledge of vaccine cold chain management. One hundred (71.4%) vaccine cold chain handlers did point correctly to the recommended range of temperature (2°C -8°C) for vaccine storage. Around two-thirds (63.6%) of them were aware of the twice-daily temperature recordings. Nearly half, (46.2%) of primary healthcare facilities have experienced poor adherence to the WHO storage practice codes. Around three-fifths of the observed primary healthcare facilities have registered undesirable vaccine management practices. The primary healthcare workers who received training on vaccine cold chain management (χ2 = 0.058, p=0.015), served at primary health care facilities for more five years (χ2 =18.545, p≤0.001), shown good adherence to WHO vaccine storage code (χ2 =18.545, p≤0.001), have sufficient knowledge on vaccine cold chain management (χ2=4.210, p≤0.031) were all significantly associated with desirable vaccine cold chain management practice.

Conclusion

There is a gap in vaccine cold chain handlers’ knowledge about vaccine cold chain management and less than desirable adherence to WHO vaccine storage codes at primary healthcare facilities in Dalocha district. The majority of the observed primary health facilities have registered poor vaccine management practices. Everyone who has a stake in the cold chain management of vaccines should do their share, individually and collectively, to guarantee that everyone reaps the benefits of an effective cold chain.

Lyophilization Process Engineering and Thermostability of ID93 + GLA-SE, a Single-Vial Adjuvanted Subunit Tuberculosis Vaccine Candidate for Use in Clinical Studies

Promising clinical efficacy results have generated considerable enthusiasm for the potential impact of adjuvant-containing subunit tuberculosis vaccines. The development of a thermostable tuberculosis vaccine formulation could have significant benefits on both the cost and feasibility of global vaccine distribution. The tuberculosis vaccine candidate ID93 + GLA-SE has reached Phase 2 clinical testing, demonstrating safety and immunogenicity as a two-vial point-of-care mixture. Earlier publications have detailed efforts to develop a lead candidate single-vial lyophilized thermostable ID93 + GLA-SE vaccine formulation. The present report describes the lyophilization process development and scale-up of the lead candidate thermostable ID93 + GLA-SE composition. The manufacture of three full-scale engineering batches was followed by one batch made and released under current Good Manufacturing Practices (cGMP). Up to 4.5 years of stability data were collected. The cGMP lyophilized ID93 + GLA-SE passed all manufacturing release test criteria and maintained stability for at least 3 months when stored at 37°C and up to 24 months when stored at 5°C. This work represents the first advancement of a thermostable adjuvant-containing subunit tuberculosis vaccine to clinical testing readiness.

Vaccine cold chain management and cold storage technology to address the challenges of vaccination programs

The outbreaks of infectious diseases that spread across countries have generally existed for centuries. An example is the occurrence of the COVID-19 pandemic in 2020, which led to the loss of lives and economic depreciation. One of the essential ways of handling the spread of viruses is the discovery and administration of vaccines. However, the major challenges of vaccination programs are associated with the vaccine cold chain management and cold storage facilities. This paper discusses how vaccine cold chain management and cold storage technology can address the challenges of vaccination programs. Specifically, it examines different systems for preserving vaccines in either liquid or frozen form to help ensure that they are not damaged during distribution from manufacturing facilities. Furthermore, A vaccine is likely to provide very low efficacy when it is not properly stored. According to preliminary studies, the inability to store vaccine properly is partly due to the incompetency of many stakeholders, especially in technical matters. The novelty of this study is to thoroughly explore cold storage technology for a faster and more comprehensive vaccine distribution hence it is expected to be one of the reference and inspiration for stakeholders.

Towards novel nano-based vaccine platforms for SARS-CoV-2 and its variants of concern: Advances, challenges and limitations

Vaccination is the most effective tool available for fighting the spread of COVID-19. Recently, emerging variants of SARS-CoV-2 have led to growing concerns about increased transmissibility and decreased vaccine effectiveness. Currently, many vaccines are approved for emergency use and more are under development. This review highlights the ongoing advances in the design and development of different nano-based vaccine platforms. The challenges, limitations, and ethical consideration imposed by these nanocarriers are also discussed. Further, the effectiveness of the leading vaccine candidates against all SARS-CoV-2 variants of concern are highlighted. The review also focuses on the possibility of using an alternative non-invasive routes of vaccine administration using micro and nanotechnologies to enhance vaccination compliance and coverage.

The status of refrigeration solutions for last mile vaccine delivery in low-income settings

Recommendations for storage of most vaccines imply a continuous exposure to a temperature range between 0 °C and 10 °C, from the production to the administration to beneficiaries. According to the World Health Organization, more than 50% of vaccines are wasted around the world. Discontinuities of the cold chain in low-income settings where electricity is scarce contributes to this wastage. Recently, several advances have been made in cooling technologies to store and transport vaccines. This paper presents an overview of refrigeration technologies based on scientific publications, industry white papers and other grey literature. With a focus on vaccine transport, we briefly describe each refrigeration method, its best performing available devices as well as the outstanding research challenges in order to further improve its performance.

Formulation of dry powders of vaccines containing MF59 or AddaVax by Thin-Film Freeze-Drying: Towards a dry powder universal flu vaccine

MF59® is an oil-in-water (O/W) nanoemulsion-based vaccine adjuvant that is often used in seasonal and pandemic influenza vaccines. We explored the feasibility of developing dry powders of vaccines adjuvanted with MF59 or AddaVax™, a preclinical grade equivalent of MF59 with the same composition and droplet size as MF59, by thin-film freeze-drying (TFFD). Liquid AddaVax alone was successfully converted to a dry powder by TFFD using trehalose as a stabilizing agent while maintaining the droplet size distribution of AddaVax after it was reconstituted. TFFD was then applied to convert liquid AddaVax-adjuvanted vaccines containing either a model antigen (e.g., ovalbumin) or mono-, bi-, and tri-valent recombinant hemagglutinin (rHA) protein-based H1 and/or H3 (universal) influenza vaccine candidates, as well as the MF59-containing Fluad® Quadrivalent influenza vaccine to dry powders. Both antigens and stabilizing agents affected the physical properties of the vaccines (e.g., mean particle size and particle size distribution) after the vaccines were subjected to TFFD. Importantly, the integrity and hemagglutination activity of the rHA antigens did not significantly change and the immunogenicity of reconstituted influenza vaccine candidates was maintained when evaluated in a mouse model. The vaccine dry powder was not sensitive to repeated freezing-and-thawing, in contrast to its liquid counterpart. It is concluded that TFFD can be applied to convert liquid vaccines containing MF59 or AddaVax to dry powders while maintaining the immunogenicity of the vaccines. Ultimately, TFFD technology may be used to prepare dry powders of multivalent universal influenza vaccines.

New theoretical ISM-K2 Bayesian network model for evaluating vaccination effectiveness

Aiming at the difficulty in obtaining a complete Bayesian network (BN) structure directly through search-scoring algorithms, authors attempted to incorporate expert judgment and historical data to construct an interpretive structural model with an ISM-K2 algorithm for evaluating vaccination effectiveness (VE). By analyzing the influenza vaccine data provided by Hunan Provincial Center for Disease Control and Prevention, risk factors influencing VE in each link in the process of "Transportation-Storage-Distribution-Inoculation" were systematically investigated. Subsequently, an evaluation index system of VE and an ISM-K2 BN model were developed. Findings include: (1) The comprehensive quality of the staff handling vaccines has a significant impact on VE; (2) Predictive inference and diagnostic reasoning through the ISM-K2 BN model are stable, effective, and highly interpretable, and consequently, the post-production supervision of vaccines is enhanced. The study provides a theoretical basis for evaluating VE and a scientific tool for tracking the responsibility of adverse events of ineffective vaccines, which has the value of promotion in improving VE and reducing the transmission rate of infectious diseases.

Experimental Study on Solidification Characteristics of Sessile Urine Droplets on a Horizontal Cold Plate Surface under Natural Convection

As the human excreta, urine is often used as one of the test materials in medical research due to its composition and content directly reflecting the health status of the body. Considering that the substances in urine may show different effects on its freezing process, solidification characteristics of sessile urine droplets on a horizontal cold plate surface under natural convection were experimentally investigated by comparing with those of water droplets under same conditions. To make the conclusion analysis more reasonable, the urine of a human without any diseases, especially metabolic diseases, was treated and used. The characteristics include nucleation location, dynamic variation of droplet color, and temperatures at different heights inside the droplet, and so forth. It was found that, similar to that of a water droplet, the solidification process of a urine droplet also experiences the following four stages: supercooling, recalescence, freezing, and cooling, in chronological order. Differently, the urine droplet changes from transparent to blur white at the supercooling stage due to the precipitation of inorganic salts. For nucleation locations, 46.67% cases are at the bottom, while others are at the top and middle of urine droplets. For a 10 μL droplet on a surface of -30 °C, urine has a 0.95 s freezing duration shorter than water, and a 5.31 °C lower phase-transition temperature. Results of this study are expected to reflect the content of substances in urine and thus provide references for urinalysis of patients with metabolic diseases.

Nanostructured Temperature Indicator for Cold Chain Logistics

Food, chemicals, agricultural products, drugs, and vaccines should be transported and stored within an appropriate low-temperature range, following cold chain logistics. Violations of the required temperature regime are generally reported by time-temperature indicators; however, current sensors do not cover a sufficiently broad low-temperature range and may lack thermal and photostability. Here, we report a nanostructured solvatochromic temperature indicator formed from cellulose nanocrystals decorated with carbon dots (C-dots). The indicator utilizes a strong nonlinear dependence of photoluminescence of C-dots on the composition of water/dimethyl sulfoxide (DMSO) solvent and a composition-dependent variation of the melting temperature of the water/DMSO mixture. Exceeding the temperature of the frozen mixed solvent above a designated threshold value results in solvent melting, flow, and impregnation of the nanostructured film, thus causing an irreversible change in the intensity and wavelength of photoluminescence emission of the film, which is reported both qualitatively and quantitatively. The indicator covers a temperature range from -68 to +19 °C and is cost-efficient, portable and photo- and thermostable.

Development of (Inhalable) Dry Powder Formulations of AS01B-Containing Vaccines Using Thin-Film Freeze-Drying

AS01_B is a liposomal formulation of two immunostimulants namely 3-O-desacyl-4́-monophosphoryl lipid A (MPL) and QS-21. The liposomal formulation of AS01_B reduces the endotoxicity of MPL and the lytic activity of QS-21. The AS01_B-adjuvanted Shingrix vaccine is marketed in a two-vial presentation, with the liquid AS01_B liposomes in one vial and the antigen as a dry powder in another vial. In the present study, we tested the feasibility of applying thin-film freeze-drying (TFFD) to engineer dry powders of the AS01_B liposomal adjuvant alone or vaccines containing AS01_B as an adjuvant. Initially, we showed that after the AS01_B liposomal adjuvant was subjected to TFFD using sucrose as a stabilizer at 4% w/v, the particle size distribution of AS01_B liposomes reconstituted from the dry powder was identical to the liquid adjuvant before drying. We then showed using ovalbumin (OVA) as a model antigen adjuvanted with AS01_B (AS01_B/OVA) that subjecting the AS01_B/OVA vaccine to TFFD and subsequent reconstitution did not negatively affect the AS01_B liposome particle size, nor the immunogenicity of the vaccine. Importantly, the thin-film freeze-dried AS01_B/OVA vaccine, unlike its liquid counterpart, was not sensitive to repeated freezing-and-thawing. The developed AS01_B/OVA dry powder also showed the desirable aerosol properties (i.e., fine particle fraction of 66.3 ± 4.9% and mass median aerodynamic diameter of 2.4 ± 0.1 µm) for potential pulmonary administration. Finally, the feasibility of using TFFD to prepare dry powders of AS01_B-adjuvanted vaccines was further confirmed using AS01_B-adjuvanted Fluzone Quadrivalent and Shingrix, which contains AS01_B. It is concluded that the TFFD technology can enable the formulation of AS01_B-adjuvanted vaccines as freezing-insensitive, inhalable dry powders in a single-vial presentation.

Investigating the performance of the sustainable cold supply chain in the pharmaceutical industry

Purpose

This study focuses on identifying potential challengers affecting cold chain performance in the pharmaceutical industry. Considering the history of humanity, every pandemic experienced could only be controlled with the vaccine found. While the world is fighting the unforgettable epidemic called COVID-19, scientists are also working to find the therapeutic vaccine. The vaccines studied have different temperature storage and transport properties. In the pharmaceutical industry, it is necessary to know and analyse every step of the cold supply chain to provide the most appropriate and safe cooling level. In addition, it is important to understand the relationship between all the facilities, equipment, tools and materials needed to avoid mistakes along the chain.

Design/methodology/approach

Hence, this study focuses on identifying potential challengers affecting sustainable cold supply chain performance in the pharmaceutical industry and proposing a conceptual framework that involves these main challengers. In this study, firstly, different main and sub-factors are defined from the literature, and fuzzy Decision Making Trial and Evaluation Laboratory method is applied to analyse the causal link between these factors for an effective application.

Findings

Results showed that packaging, transportation and shipping, storage specifications and handling practices, inventory management, technical issues and delivery delay are the most affected factors during the sustainable cold supply chain performance in the pharmaceutical industry. This study offers both managerial implications and a roadmap that are designed with a holistic view to guide manufacturer, logistics parties and even policymakers.

Originality/value

Some of the studies related to the pharmaceutical industry are monitoring and controlling the temperature in the cold supply chain steps; the other part is the studies where the chain steps are examined with a focus on production or transportation. While these issues are the focus, the requirements and conditions of each stage of the supply chain must be studied for a safe, effective and sustainable cold chain beyond the current global pandemic crisis. To the best of the authors’ knowledge, this is the first study that highlights identifying the potential challengers that affect cold supply chain performance for the pharmaceutical industry both theoretically and empirically, solving the causal relationships among these challengers and designing a holistic framework.

Mechanistic elucidation of freezing-induced surface decomposition of aluminum oxyhydroxide adjuvant

The freezing-induced aggregation of aluminum-based (Alum) adjuvants has been considered as the most important cause of reduced vaccine potency. However, the intrinsic properties that determine the functionality of Alum after freezing have not been elucidated. In this study, we used engineered aluminum oxyhydroxide nanoparticles (AlOOH NPs) and demonstrated that cryogenic freezing led to the mechanical pressure-mediated reduction of surface hydroxyl. The sugar-based surfactant, octyl glucoside (OG), was demonstrated to shield AlOOH NPs from the freezing-induced loss of hydroxyl content and the aggregation through the reduction of recrystallization-induced mechanical stress. As a result, the antigenic adsorption property of frozen AlOOH NPs could be effectively protected. When hepatitis B surface antigen (HBsAg) was adjuvanted with OG-protected frozen AlOOH NPs in mice, the loss of immunogenicity was inhibited. These findings provide insights into the freezing-induced surface decomposition of Alum and can be translated to design of protectants to improve the stability of vaccines.

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The freezing stress led to the destruction of surface hydroxyl group on AlOOH NPs

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Octyl glucoside protected AlOOH NPs from freezing-induced surface decomposition

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Octyl glucoside protected vaccines from freezing-induced loss of immunogenicity

A LAG-based framework to overcome the challenges of the sustainable vaccine supply chain: an integrated BWM–MARCOS approach

Purpose

Each individual needs to be vaccinated to control the spread of the COVID-19 pandemic in the shortest possible time. However, the vaccine distribution with an already strained supply chain in low- and middle-income countries (LMICs) will not be effective enough to vaccinate all the population in stipulated time. The purpose of this paper is to show that there is a need to revolutionize the vaccine supply chain (VSC) by overcoming the challenges of sustainable vaccine distribution.

Design/methodology/approach

An integrated lean, agile and green (LAG) framework is proposed to overcome the challenges of the sustainable vaccine supply chain (SVSC). A hybrid best worst method (BWM)–Measurement of Alternatives and Ranking According to COmpromise Solution (MARCOS) methodology is designed to analyze the challenges and solutions.

Findings

The analysis shows that vaccine wastage is the most critical challenge for SVSC, and the coordination among stakeholders is the most significant solution followed by effective management support.

Social implications

The result of the analysis can help the health care organizations (HCOs) to manage the VSC. The effective vaccination in stipulated time will help control the further spread of the virus, which will result in the normalcy of business and availability of livelihood for millions of people.

Originality/value

To the best of the author's knowledge, this is the first study to explore sustainability in VSC by considering the environmental and social impact of vaccination. The LAG-based framework is also a new approach in VSC to find the solution for existing challenges.

Using long-range freeze-preventive vaccine carriers in Nepal: A study of equipment performance, acceptability, systems fit, and cost

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Freeze-preventive vaccine carriers successfully prevent vaccine freezing.

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The technology was shown to be cost effective.

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Both short-range and long-range freeze-preventive carriers are needed.

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Weight and size were a concern for many health workers.

Preventing vaccine freezing is one of the biggest challenges in vaccine management. Until 2018, vaccine carriers used in the immunization program lacked features to prevent vaccine freezing. Freeze-preventive vaccine carriers (FPVCs) have an engineered liner that buffers vaccines from direct exposure to frozen ice packs. A field evaluation of three FPVCs was conducted in 24 health posts in eastern Nepal. The objective was to evaluate the FPVCs’ performance, acceptability, systems fit, and cost, to inform prequalification and introduction planning. The study was carried out in two phases: in the first phase, FPVCs containing dummy vaccines (labeled “Not for Human Use”) were transported to outreach sessions along with a standard vaccine carrier (SVC); in the second phase, the FPVCs were used for transporting vaccines taken to outreach sessions and used for vaccinating eligible children. The study gathered quantitative and qualitative data from health workers, logbooks, and electronic temperature monitors placed inside and outside the FPVCs. Results indicate the FPVCs successfully prevented temperatures below 0 °C more than 99% of the time—except at one site, where ambient temperatures were below the minimum rated testing temperature specified by the World Health Organization. Internal cool-down times for the FPVCs were highly variable, as were mean kinetic temperatures, possibly driven by the wide range of ambient temperatures and higher-than-expected variations in freezer performance, which, along with the need to transport ice packs to some locations, affected ice-pack temperatures. Almost all health workers requested smaller, lighter-weight FPVCs but appreciated the FPVCs’ ability to prevent vaccines from freezing while avoiding undue heat exposure. FPVCs had benefit-cost ratios greater than 1 and hence good value for money. Results point to the importance of understanding the intended environment of use and the need for smaller, short-range as well as long-range carriers.

A fuzzy decision framework of lean-agile-green (LAG) practices for sustainable vaccine supply chain

Purpose

The already-strained vaccine supply chain (VSC) of the expanded program for immunization (EPI) require a more robust and structured distribution network for pandemic/outbreak vaccination due to huge volume demand and time constraint. In this paper, a lean-agile-green (LAG) practices approach is proposed to improve the operational, economic and environmental efficiency of the VSC.

Design/methodology/approach

A fuzzy decision framework of importance performance analysis (IPA)–analytical hierarchy process (AHP)–technique for order for preference by similarity in ideal solution (TOPSIS) has been presented in this paper to prioritize the LAG practices on the basis of the influence on performance indicators. Sensitivity analysis is carried out to check the robustness of the presented model.

Findings

The derived result indicates that sustainable packaging, coordination among supply chain stakeholders and cold chain technology improvement are among the top practices affecting most of the performance parameters of VSC. The sensitivity analysis reveals that the priority of practices is highly dependent on the weightage of performance indicators.

Practical implications

This study's finding will help policymakers reframe strategies for sustainable VSC (SVSC) by including new management practices that can handle regular immunization programs as well as emergency mass vaccination.

Originality/value

To the best of the authors' knowledge, this is the first study that proposes the LAG framework for SVSC. The IPA–Fuzzy AHP (FAHP)–Fuzyy TOPSIS (FTOPSIS) is also a novel combination in decision-making.

Adverse drug reactions from two COVID-19 vaccines reported in Saudi Arabia

Background

Several reports have been published about the impact of coronavirus disease 2019 (COVID-19) vaccines on human health, and each vaccine has a different safety and efficacy profile. The aim of this study was to reveal the nature and classification of reported adverse drug reactions (ADRs) of the two COVID-19 vaccines (tozinameran and ChAdOx1) among citizens and residents living in Saudi Arabia, and show possible differences between the two vaccines and the differences between each batch on the health of populations.

Methods

A cross-sectional study was conducted in Saudi Arabia between December 2020 and March 2021. Saudi citizens and residents aged ≥ 16 years who had at least one dose of any batch of either of the two approved COVID-19 vaccines (tozinameran and ChAdOx1) and who reported at least one ADR from the vaccines were included. The study excluded people who reported ADRs after receiving tozinameran or ChAdOx1 vaccines but no information was provided about the vaccine’s batch number.

Results

During the study period, 12,868 vaccinated people, including a high-risk group (i.e., those with chronic illness or pregnant women), reported COVID-19 vaccine ADRs that had been documented in the General Directorate of Medical Consultations, Saudi Ministry of Health. The study reported several ADRs associated with COVID-19 vaccines, with the most common (> 25%) being fever/chills, general pain/weakness, headache, and injection site reactions. Among healthy and high-risk people, the median onset of all reported ADRs for tozinameran and ChAdOx1 vaccine batches were 1.96 and 1.64 days, respectively (p < 0.01). Furthermore, significant differences (p < 0.05) were recorded between the two studied vaccines in regard to fever/chills, gastrointestinal symptoms, headache, general pain/weakness, and neurological symptoms, with higher incidence rates of these ADRs observed with the ChAdOx1 vaccine than the tozinameran vaccine. However, the tozinameran vaccine was found to cause significantly (p < 0.05) more palpitation, blood pressure variations, upper respiratory tract symptoms, lymph node swelling, and other unspecified ADRs than the ChAdOx1 vaccine. Among patients vaccinated with seven different batches of the tozinameran vaccine, people vaccinated with the T4 and T5 batches reported the most ADRs.

Conclusion

There were significant differences regarding most of the reported ADRs and their onset among tozinameran and ChAdOx1 vaccines on both healthy people and high-risk individuals living in Saudi Arabia. Moreover, the study found that the frequencies of most listed ADRs were statistically different when seven batches of tozinameran vaccine were compared.

Battery-Free Shape Memory Alloy Antennas for Detection and Recording of Peak Temperature Activity

Economical sensing and recording of temperatures are important for monitoring the supply chain. Existing approaches measure the entire temperature profile over time using electronic devices running on a battery. This paper presents a simple, intelligent, battery-free solution for capturing key temperature events using the natural thermo-mechanical state of a Shape Memory Alloy (SMA). This approach utilizes the temperature-induced irreversible mechanical deformation of the SMA as a natural way to capture the temperature history without the need for electronic data logging. In this article, two-way SMA is used to record both high-temperature and low-temperature peak events. Precise thermo-mechanically trained SMA are employed as arms of the dipole antenna for Radio Frequency (RF) readout. The fabricated antenna sensor works at 1 GHz and achieves a sensitivity of 0.24 dB/°C and −0.16 dB/°C for recording temperature maxima and minima, respectively.

Internet of Things use case applications for COVID-19

The Internet of Things (IoT) is a technology built upon various physical objects equipped with different types of sensors, which are connected together using communication methods. These devices have been applied to several domains, especially healthcare. In addition to the numerous benefits that IoT has demonstrated in healthcare, this technology is being adopted for combating the recent COVID-19 pandemic. The key role of IoT in COVID-19 could be classified into five major tasks: Monitoring, Diagnosing, Tracing, Disinfecting, and Vaccinating. This chapter reviews the state-of-art applications of IoT based on these tasks in order to better mitigate this virus. Additionally, potential areas for applying IoT systems to fight against COVID-19 or even future pandemics will be demonstrated.

Orthogonal modular biosynthesis of nanoscale conjugate vaccines for vaccination against infection

Conjugate vaccines represent one of the most effective means for controlling the occurrence of bacterial diseases. Although nanotechnology has been greatly applied in the field of vaccines, it is seldom used for conjugate vaccine research because it is very difficult to connect polysaccharides and nanocarriers. In this work, an orthogonal and modular biosynthesis method was used to produce nanoconjugate vaccines using the SpyTag/SpyCatcher system. When SpyTag/SpyCatcher system is combined with protein glycosylation technology, bacterial O-polysaccharide obtained from Shigela flexneri 2a can be conjugated onto the surfaces of different virus-like particles (VLPs) in a biocompatible and controlled manner. After confirming the excellent lymph node targeting and humoral immune activation abilities, these nanoconjugate vaccines further induced efficient prophylactic effects against infection in a mouse model. These results demonstrated that natural polysaccharide antigens can be easily connected to VLPs to prepare highly efficient nanoconjugate vaccines. To the best of the researchers' knowledge, this is the first time VLP-based nanoconjugate vaccines are produced efficiently, and this strategy could be applied to develop various pathogenic nanoconjugate vaccines.

ELECTRONIC SUPPLEMENTARY MATERIAL

Supplementary material (Figs. S1-S9) is available in the online version of this article at 10.1007/s12274-021-3713-4.

Evaluation of precipitation time of the aluminum salts adsorbed potentially frozen vaccines used in the Polish National Immunization Schedule for their pre-qualification before the administration

Purpose

Vaccines adsorbed on aluminum adjuvants irreversibly lose potency after freezing and their safety is affected. To prevent the administration of such vaccines, the World Health Organization developed the Shake Test designed to determine whether adsorbed vaccines have been frozen or not. However, the Shake Test is difficult and time-consuming when routinely conducted at the place of vaccination. In this study, a modified shake test for prequalification of potentially frozen vaccines was elaborated.

Materials and Methods

Vaccines used in the Polish Immunization Schedule were investigated and the analysis includes an assessment of precipitation time and the influence of the container type, amount and type of aluminum compound, and a volume of vaccine dose on the precipitation time.

Results

Significant differences between the precipitation time of frozen and non-frozen vaccines routinely used in the Polish Immunization Schedule were observed. The precipitation time of all non-frozen vaccines was above 30 minutes. The longest precipitation time of frozen vaccines was 10 minutes.

Conclusion

The finding of the study can be used in practice by the personnel administering vaccines to patients. Step-by-step recommendations for the preparation of the test have been proposed in the article.

Route Optimization Tool (RoOT) for distribution of vaccines and health products

Ensuring the delivery and availability of health products, including temperature-sensitive vaccines, is vital to saving lives in low- and middle-income countries (LMICs).  In many LMICs routes are hand drawn by logisticians and are adjusted based on vehicle availability and product quantities. Easy-to-use real-time supply chain tools are needed to create or adjust routes for available vehicles and road conditions. Having more efficient and optimized distribution is especially critical for COVID-19 vaccine distribution.

Route Optimization Tool (RoOT) works best for planning routes for 50 health facilities or less, in two minutes. We develop RoOT using a variant of a Vehicle Routing and Scheduling Algorithm (VeRSA) that is coded in Python but reads and writes Excel files to make data input and using outputs easier. RoOT can be used for routine operations or in emergency situations, such as delivery of new COVID-19 vaccine. The tool has a user-centric design with easy dropdown menus and the ability to optimize on time, risk, or combination of both. RoOT is an open-source tool for optimal routing of health products. It provides optimized routes faster than most commercial software and is tailored to meet the needs of government stakeholders

We trained supply chain logisticians in Mozambique on using RoOT, and their feedback validates that RoOT is a practical tool to improve planning and efficient distribution of health products, especially vaccines. We also illustrate how  RoOT can be adapted for an emergency situation by using a test scenario of a cyclone. Currently, RoOT does not allow multi-day routes, and is designed for trips that can be completed within twenty-four hours. Areas for future development include multi-day routing and integration with mapping software to facilitate distance calculations and visualization of routes.

Critical prerequisites for Covid-19 vaccine acceleration: A developing economy perspective

This study aims to explore the critical prerequisites for accelerating the distribution of the COVID-19 vaccine in developing countries by using Ghana as a case study. A qualitative study method and content analysis approach was used. In-depth interviews were conducted with health experts from the Ghana Health Service, World Health Organization (WHO), AstraZeneca, Novartis, and Medtronic Inc. in Ghana. Our analysis of data revealed that new structures, committees, advisory bodies and lines of communication in government evolved during this pandemic and are underlying the current strategy development and decision-making on COVID-19 vaccines. The interviews gave insights into six major factors that will aid COVID-19 vaccine acceleration in Ghana. These factors are: (1) Access to vaccines through delivery, (2) national manufacturing of vaccines, (3) choosing the best vaccine candidates, (4) financial resources, (5) transparency, and (6) vaccine roll-out and administration. These results could guide policymakers and other relevant stakeholders in prioritizing activities that will aid COVID-19 vaccine acceleration in Ghana and other lower-middle-income countries, tailored to their specific context. As a recommendation, the Ghanaian government should embrace a multisectoral synergy approach to fight the disease. The study also provides insights into how vaccine adoption can be accelerated in the case of future pandemics.

Strengthening the immunization supply chain: A time-to-supply based approach to cold chain network optimization & extension in Madhya Pradesh

Expansion of immunization coverage is dependent in part on delivering potent vaccines in an equitable and timely manner to immunization outreach session sites from Cold Chain Points (CCPs). When duration of travel between the last CCP and the session site (Time-to-Supply) is too long, three consequences may arise: decreased potency due to exposure to heat and freezing, beneficiary dropouts due to delayed session starts, and, increased operational costs for the Health Facility (HF) conducting the outreach sessions. Guided by the Government of India’s recommendation on cold chain point expansion to ensure that all session sites are within a maximum of 60 min from the last CCP, CHAI and the State Routine Immunization Cell in the state of Madhya Pradesh collaborated to pilot a novel approach to cold chain network optimization and expansion in eight districts of Madhya Pradesh. Opportunities for realignment of remote sub-health centers (SHCs) and corresponding session sites to alternative existing CCPs or to HFs which could be converted to new CCPs were identified, and proposed using a greedy adding algorithm-based optimization which relied on health facility level geo-location data. Health facility geo-coordinates were collected through tele-calling and site visits, and a Microsoft Excel based optimization tool was developed.

This exercise led to an estimated reduction in the number of remote SHCs falling beyond the permissible travel time from CCPs by 56.89 percent (132 remote sites), from 232 to 100. The 132 resolved sites include 73 sites realigned to existing CCPs, and 59 sites to be attached to 22 newly proposed CCPs. Both the network optimization approach and the institutional capacity built during this project will continue to be useful to India’s immunization program. The approach is replicable and may be leveraged by developing countries facing similar challenges due to geographical, institutional, and financial constraints.

Cold Chain Management by Healthcare Providers at a District in Ghana: A Mixed Methods Study

Background

Despite the relevance of cold chain management in maintaining the potency of vaccines, gaps still exist in the ability of healthcare practitioners to maintain the cold chain system effectively. Thus, the current study sought to assess healthcare providers' knowledge, attitudes, practices, and challenges regarding cold chain management.

Methods

A concurrent mixed methods study was conducted at twelve facilities in the Sekyere Central District of Ghana. Eighty-six (86) participants took part in a survey that assessed their “cold chain management” knowledge and attitudes. Twelve (12) cold chain sites within the district were also observed in respect of their cold chain management practices. Eleven key informants were additionally interviewed to explore their challenges on cold chain management. Quantitative data were analyzed using descriptive (frequencies, percentages, means, standard deviations, ranges) and inferential statistics (Spearman's rho correlation). Qualitative data were inductively analyzed into themes which described participants' challenges on cold chain management.

Results

Majority of the participants scored ≥70% on knowledge (68.6%) and attitudes (67.4%) toward cold chain management. However, there was a very weak positive and statistically insignificant relationship between participant's knowledge and attitudes toward cold chain management (r = 0.109, p = 0.317). Regarding cold chain management practices, majority of the facilities had their vaccine vial monitors attached to the vaccines (8/12, 66.7%), had functional fridge tags (8/12, 66.7%), and an appropriate refrigerator to store vaccines (7/12, 58.3%). However, the study observed that 91.7% (11/12) of the facilities did not have policies and guidelines on cold chain management while all 12 facilities (100%) did not have a contingency plan in place for equipment. With regards to the cold chain management challenges, participants raised concerns about inadequate personnel, erratic power supply, logistical constraints, and transportation difficulties.

Conclusion

Although majority of the participants had good knowledge and attitude towards cold chain management, there was a weak association between them. This implies that good knowledge may not necessarily influence good attitudes towards cold chain management and vice versa. The extent to which facilities support cold chain management practices was suboptimal. Participants encountered a number of challenges which prevented them from managing the vaccine cold chain system effectively. We recommend continual professional education for cold chain practitioners, provision of adequate human and material resources for cold chain management, and enhanced monitoring and evaluation of cold chain activities. Future studies should quantitatively measure individual participants' knowledge, attitudes, practices, and challenges on cold chain management so that we can establish the relationships that exist between these components.

A light-touch routing optimization tool (RoOT) for vaccine and medical supply distribution in Mozambique

Planning vaccine distribution in rural and urban poor communities is challenging, due in part to inadequate vehicles, limited cold storage, road availability, and weather conditions. The University of Washington and VillageReach jointly developed and tested a user-friendly, Excel spreadsheet based optimization tool for routing and scheduling to efficiently distribute vaccines and other medical commodities to health centers across Mozambique. This paper describes the tool and the process used to define the problem and obtain feedback from users during the development. The distribution and routing tool, named route optimization tool (RoOT), uses an indexing algorithm to optimize the routes under constrained resources. Numerical results are presented using five datasets, three realistic and two artificial datasets. RoOT can be used in routine or emergency situations, and may be easily adapted to include other products, regions, or logistic problems.

Adequacy assessment of immunobiological agent conservation in the Western Health macro-region of Minas Gerais State, Brazil: a descriptive study, 2017

OBJECTIVE

To describe the adequacy of immunobiological agent conservation in vaccination rooms in the municipalities of the Western health macro-region of the state of Minas Gerais, Brazil.

METHODS

This was a descriptive study, based on a validated scale, with a maximum score of 15 points. A descriptive analysis and an association test between the scores obtained by the municipalities and variables of the external context were performed.

RESULTS

275 out of a total of 295 existing vaccination rooms were evaluated. Immunobiological agent conservation in the West macro-region obtained an average score of 4 points (standard score, 0 to 15). There was a poor availability of immunization supplies aimed at immunobiological agent conservation, and work processes, that require improvement. Small municipalities presented better immunobiological agent conservation (p=0.011).

CONCLUSION

Immunobiological agent conservation in vaccination rooms in the Western health macro-region of Minas Gerais State was considered inadequate.

Application and research progress of phase change materials in biomedical field

Phase change materials (PCMs) are widely used in solar energy utilization, industrial waste heat recovery and building temperature regulation. However, there have been few studies on the application of PCMs in the field of biomedicine. In recent years, some scholars have carried out research in the biomedicine field using the characteristics of PCMs. It was observed that the excellent properties of PCMs enhance the quality of a variety of biomedical applications with many advantages over existing applications, which provide new methods for the treatment of disease. PCMs have broad application prospects in the field of biomedicine. Therefore, a timely review of relevant research progress is of great significance for the continuous development of new methods. Innovatively, from the unique perspective of the biomedical field, this paper systematically reviews the application and related research progress of PCMs from four aspects: cold chains for vaccines and medicines, drug delivery systems, thermotherapy/cold compress therapy and medical dressings. In addition, we summarize and discuss the general principles of the design and construction of PCMs in the biomedical field. Finally, existing problems, solutions and future research directions are also put forward in order to provide a basis for guidance and promote the future applications of phase change materials in the biomedicine field.

Impact of educational intervention on the best immunization practices among practicing health care professionals in a south Indian city

Background and Aims

Maintaining the quality and safety of immunization is as important as the efficacy of vaccines in vaccine-preventable diseases (VPD) programs. The aim of this study was to determine the problems associated with different stages of vaccine use and to assess the outcome of an educational intervention on safety and quality use of vaccines among health care providers.

Methods

A pilot prospective interventional study was conducted over a period of 2 years at 271 sites in Mysuru, India. The study population was health care professionals (HCPs) involved in immunization and a sample of parents (one per site). A validated questionnaire was used as a study tool. An educational intervention on best immunization practice was conducted for the enrolled HCPs and the impact of the educational intervention was assessed using the study tool after 3 weeks.

Results

The total number of the study population was 594 (323 HCPs and 271 parents). Of these, 41.49% were working at community health care facility and 33.13% were enrolled from primary care centers. There were statistically significant improvements in post interventional assessment of all stages of the immunization process including storage (p -0.001), transportation (p -0.001), administration (p 0.001), monitoring and reporting of adverse events following immunization (AEFIs) (p -0.001), knowledge of AEFIs (p 0.001), and HCP-parent communication (p 0.001). AEFI reporting improved by 30% in the post education phase.

Conclusion

Continuous education and motivation can result in positive behavioral changes on best immunization practices amongst HCPs involved in immunization, which may help to improve and maintain the safety and quality use of vaccines in immunization centers irrespective of the type of facility.

Cold Chain Maintenance and Vaccine Stock Management Practices at Public Health Centers Providing Child Immunization Services in Jimma Zone, Oromia Regional State, Ethiopia: Multi-Centered, Mixed Method Approach

Background

Cold chain maintenance is the spine of an immunization program.

Objective

To examine the status of cold chain maintenance and evaluate knowledge of cold chain handlers and practices of vaccine management at public health centers providing immunization services in Jimma zone.

Methods

An institutional-based cross-sectional study supplemented with a qualitative method was conducted in 41 randomly selected health centers providing immunization service in districts of Jimma zone from October 31 to November 30, 2019. Pre-tested self-administered questionnaires and observation checklists developed from an effective vaccine management assessment tool (EVMAT) were used to collect quantitative data. Key informants were selected using the purposive sampling technique and an in-depth interview was conducted. Quantifiable data were analyzed using SPSS version 20 and chi-square was used to test the presence of association (p-value <0.05). Qualitative data were analyzed by thematic analysis and triangulated with quantitative findings.

Results

All public health centers had at least functional ice-lined refrigerators while 28 (68.3%) public health centers had functional deep freezers. Of the cold chain handlers, 120 (82.9%) had fair knowledge. Vaccine storage was appropriate per the World Health Organization's vaccine storage code in ice-lined refrigerators in 11 (24.4%) public health centers. Cold chain handlers’ years of service, types of training, availability of funds for cold chain maintenance, and availability of cold chain equipment at public health centers showed the presence of significant association with vaccine cold chain management practice.

Conclusion

The majority of cold chain handlers showed inadequate knowledge while a significant number showed poor practice of preserving the vaccines’ cold chain. Cold chain maintenance was not adequate in public health centers, necessitating attentive efforts of providing proper management of vaccine cold chains at immunization delivery points.

Development of thermostable vaccine adjuvants

INTRODUCTION

The importance of vaccine thermostability has been discussed in the literature. Nevertheless, the challenge of developing thermostable vaccine adjuvants has sometimes not received appropriate emphasis. Adjuvants comprise an expansive range of particulate and molecular compositions, requiring innovative thermostable formulation and process development approaches.

AREAS COVERED

Reports on efforts to develop thermostable adjuvant-containing vaccines have increased in recent years, and substantial progress has been made in enhancing the stability of the major classes of adjuvants. This narrative review summarizes the current status of thermostable vaccine adjuvant development and looks forward to the next potential developments in the field.

EXPERT OPINION

As adjuvant-containing vaccines become more widely used, the unique challenges associated with developing thermostable adjuvant formulations merit increased attention. In particular, more focused efforts are needed to translate promising proof-of-concept technologies and formulations into clinical products.

Depiction of possible solutions to improve the cold supply chain performance system

Purpose

A poor performance of the cold supply chain (CSC) may increase the loss of quality and potency of perishables and temperature-sensitive products that deteriorate the financial and environmental aspects of the same. The purpose of the current research work is to identify the critical performance factors (criteria) and their co-factors (sub-criteria) that are responsible for the performance measurement of CSC and suggest the best possible solutions (alternatives) to improve the same.

Design/methodology/approach

To achieve the objective of the research, a hierarchical model has been developed and analyzed using Analytic Hierarchy Process (AHP)-Fuzzy TOPSIS as a hybrid approach to obtain the severity weights of the identified criteria and prioritization toward their relative importance for the best possible alternatives.

Findings

Analysis reveals that the criteria “energy consumption” comes out to be the most critical criteria, and alternative “application of passive cold devices” is the most effective solution for improving the performance of CSC. Higher energy consumption leads to a higher rate of greenhouse gas (GHG) emissions increasing the global warming phenomenon, high operational cost and degradation of natural energy resources. The Application of Passive Cold Devices (PCDs) utilizes solar energy to operate the refrigeration units reducing the energy consumption, environmental and operating cost of CSC.

Research limitations/implications

The research work provides several insights into the critical issues related to the CSC and suggests significant findings that enable the management and decision-makers to adopt these practices for performance evaluation and improvement of the same. The key findings of the work, such as “application of passive cold devices” and “application of IoT in cold chain logistics”, facilitate an improved platform to improve the CSC performance and proposed several directions that will enhance the merit of future research.

Originality/value

The presented study consolidates the various perspectives associated with CSC performance, explores the most critical criteria and proposes the best suitable cold chain practices for organizational growth. The work also provides an analytical analysis with the essence of practicalities and sensitivity analysis to support the robustness of the results. By enriching the literature and quantitative analysis of the new proposed model, this paper forms vast managerial and research implications in the field of CSC.

Next-Generation COVID-19 Vaccines Should Take Efficiency of Distribution into Consideration

The dire need for safe and effective coronavirus disease (COVID-19) vaccines is met with many vaccine candidates being evaluated in pre-clinical and clinical studies. The COVID-19 vaccine candidates currently in phase 3 or phase 2/3 clinical trials as well as those that recently received emergency use authorization (EUA) from the United States Food and Drug Administration (FDA) and/or other regulatory agencies worldwide require either cold (i.e., 2–8°C) or even freezing temperatures as low as −70°C for storage and distribution. Thus, existing cold chain will struggle to support both the standard national immunization programs and COVID-19 vaccination. The requirement for cold chain is now a major challenge towards worldwide rapid mass vaccination against COVID-19. In this commentary, we stress that thermostabilizing technologies are available to enable cold chain-free vaccine storage and distribution, as well as potential needle-free vaccination. Significant efforts on thermostabilizing technologies must now be applied on next-generation COVID-19 vaccines for more cost-effective worldwide mass vaccination and COVID-19 eradication.