Knowledge, attitude and practice of vaccinators and vaccine handlers on vaccine cold chain management in public health facilities, Ethiopia: Cross-sectional study

BACKGROUND

Effective management of the vaccine cold chain system at all levels is one of the crucial factors for maintaining vaccine potency. Vaccines require more complex handling and storage requirements due to increased temperature sensitivity and complicated immunization schedules. This urges adequate knowledge, attitude, and practice. This study assessed the knowledge, attitude, and practice of vaccinators and vaccine handlers' in public health facilities.

METHODOLOGY

An institutional-based cross-sectional study design was used to assess the knowledge, attitude, and practice of 127 vaccinators and vaccine handlers in public health facilities of Oromia Special Zone, from September 1 to 30, 2019. Data were collected using self-administered questionnaires and a structured observation checklist. Descriptive and inferential statistics were made using the statistical package for social sciences version 20. Variables with a p-value <0.05 were taken as statistically significant.

RESULT

The response rate was (96.94%). Sixty-eight (53.5%; 95% CI: 46.5%, 61.4%), 58 (45.7%; 95% CI: 37.8%, 53.5%) and 62 (48.8%: 95% CI; 41.7%, 56.7%) vaccinators and vaccine handlers had satisfactory knowledge, positive attitude and good practice respectively. Receiving training on cold chain management had a statistically significant association with the level of knowledge on cold chain management (AOR = 3.04, 95% CI: 1.04-8.88).

CONCLUSIONS

More than half of vaccinators and vaccine handlers had satisfactory knowledge, while below half of vaccinators and vaccine handlers had a positive attitude and good practice. The determinants of knowledge in cold chain management were receiving training on cold chain management. Providing regular technical support and on the job training on vaccine cold chain management will improve the knowledge, attitude, and practice of vaccinators and vaccine handlers.

Comparative Effects of Carum copticum Essential Oil on Bacterial Growth and Shiga-Toxin Gene Expression of Escherichia coli O157:H7 at Abused Refrigerated Temperatures

Abused refrigerated temperatures are described as unacceptable deviations from the optimal temperature, occurring frequently during transportation of food products. Escherichia coli O157:H7 is a serious contaminant of meats and meat products due to its ability to grow at abused temperatures (> 10 °C). The aim of this study was to evaluate the antibacterial activity of Carum copticum essential oil for the control of Escherichia coli O157:H7 using laboratory media and minced beef at severe abused refrigerated temperature (15 °C). A comparative quantitative reverse transcription real-time PCR was used to assess effects of temperature and Carum copticum essential oil at sub-minimum inhibitory concentrations on bacterial growth and Shiga-toxin gene (stx1A and stx2A) expression. Results indicated that Carum copticum essential oil inhibited growth of E. coli O157:H7 in tryptone soy broth (TSB) media at all sub-MIC values until Hour 48. However, bacterial population increased progressively until Hour 72 at essential oil concentration of 0.75% (ml g^-1) and reached 8.6 log CFU g^-1 in minced beef. The essential oil at concentration of 0.005% (ml g^-1) increased stx gene expression at all times, but increased stx gene expression (0.015%) at Hour 24 in TSB media. The expression rate of stx1A in minced beef decreased progressively (10.39 and 7.67 folds for 0.5 and 0.75%, respectively) and expression of stx2A was variable in minced beef during storage. In conclusion, results from this study have shown that effects of Carum copticum essential oil on growth and virulence gene expression are not necessarily correlated and temperature, essential oil concentration, investigated gene type, and bacterial growth environment (in vivo or in vitro) are effective as well.

Commercially Available Insulin Products Demonstrate Stability Throughout the Cold Supply Chain Across the U.S

OBJECTIVE

A recent publication questioned the integrity of insulin purchased from U.S. retail pharmacies. We sought to independently validate the method used, isotope dilution solid-phase extraction (SPE) liquid chromatography mass spectrometry (LC-MS), and expand analysis to two U.S. Pharmacopeia (USP) methods (high-performance LC with ultraviolet detection and LC-MS).

RESEARCH DESIGN AND METHODS

Each method was used to evaluate nine insulin formulations, purchased at four pharmacies, within five geographic locations in the U.S.

RESULTS

All human and analog insulins measured by the USP methods (n = 174) contained the expected quantity of active insulin (100 ± 5 units/mL). When using isotope dilution SPE-LC-MS, units-per-milliliter values were well below product labeling due to unequal recovery of the internal standard compared with target insulin.

CONCLUSIONS

Insulin purchased from U.S. pharmacies is consistent with product labeling.

A comparative assessment of cold chain management using the outbreak of circulating vaccine-derived polio virus type 2 as a surrogate marker in Oyo State, Nigeria-2019

Introduction

inspite of the demonstrable evidence of the preventive and protective ability of vaccines to reduce the outbreak of vaccine-preventable diseases, there are still some significant disease outbreaks recorded in our communities. In some settings, these outbreaks have been linked with poor vaccine management. Therefore, this study was conducted to compare the cold chain practices in Oyo State, Nigeria.

Methods

we conducted a cross-sectional survey among health workers in the local government areas of Oyo State between October and November 2019. Using purposive sampling, we recruited all the 84 routine immunization focal persons for the study. A self-administered questionnaire was used to collect data on cold chain management. Data were analyzed using SPSS version 24 and bivariate analysis was done using Chi-square. Statistical significance was set at p < 0.05.

Results

the mean age of the respondents was 46.4 ± 6.7 years. Most prevalent cadre in the rural facilities was health assistants (87.5%) while Community Extension Health Workers (54.8%) were prevalent in the urban (p = 0.002). The proportion of respondents with adequate cold chain equipment was significantly higher in the urban compared with the rural area. The cold boxes were the only adequate cold chain equipment found in the rural health facilities compared with the urban (p = 0.036).

Conclusion

there was a low proportion of qualified health workers and inadequate cold chain equipment in the rural area compared with the urban facilities. Engagement of skilled health workers and supply of the cold chain equipment are recommended.

Storage of vaccines in different health centers and pharmacies at Karachi, Pakistan: The handling errors

The fundamental human desire is prevention from the infectious disease. Vaccine is the basic element to fulfill this human craving. The proper handling of vaccine can minimize the degradation. The main aim of this study is to find out the knowledge of respondents and storage condition and handling of marketed vaccines in different private clinics, hospitals and community pharmacies in Karachi, Pakistan. The present study revealed that ~77% have been allowed to visit their vaccine storage compartment. The cumulative knowledge of respondents regarding recommended temperature, shake test, thermal, freezing and photo degradation were 49.34%, 24.01%, 95.78%, 54.35% and 47.23% respectively. The major mishandling like the medicines, food and drinks and even laboratory specimen have been noticed 76.3%, 61.62% and 5.35% respectively. Moreover, water filled bottles on upper, lower and door shelves and ice packs or ice trays 3.43% and 14.18%, respectively, have been found in refrigerators and freezers, respectively. No expired vaccines have been found. The major consequence, in the study has been found to be mishandling by the absence of non-professional personnel. Either doctors or pharmacist (health associated professionals) as respondents were nearly all aware about the consequences of the mishandling of vaccines and have the knowledge about the recommended temperature, thermal, photo degradation, and freezing hazards of vaccines. The world-renowned immunization authorities have strongly recommended national/local immunization programs. On the basis of the present study, it is recommended to train the staff and prepare a national guideline for the storage and handling of vaccines, and forcefully implements the law to adopt the particular guideline.

Review of guidelines on expression, storage and transport of breast milk for infants in hospital, to guide formulation of such recommendations in Sri Lanka

BACKGROUND

Sick newborns in neonatal units who are unable to breastfeed are fed expressed breast milk. In Sri Lanka, most mothers stay in hospital throughout baby's stay to provide this milk freshly. In other countries mothers go home, express breast milk at home and bring it to hospital. There are concerns about the safety of transported expressed milk if used in a tropical middle-income country. The aim of this paper is to compare and contrast advice offered by different hospitals and organizations on how to express, store and transport breast milk safely.

METHODS

We assessed guidelines used by hospital staff of the four Level 3 neonatal units in Melbourne, Australia, National Health Service UK, guidelines and training manuals of the Human Milk Banking Association of North America, the World Health Organization and an information leaflet from Family Health Bureau, Sri Lanka. Information on breast milk expression, storage and transport provided by the guidelines were tabulated under seven topics: general information; container for milk collection; hand expression; using a pump for expression; storage; thawing / warming; and transport of expressed breast milk. The AGREE II tool was used to assess the guidelines written for hospital staff.

RESULTS

There was considerable agreement on most recommendations provided by these sources, but no single source covered all topics in full. Most recommend hand expression as the initial method for expressing of breast milk, followed by breast pump use, except the Sri Lankan recommendations which strongly discourages the use of breast pumps. Durations of storage under various conditions are generally similar in the different recommendations. Most guidelines recommend a 'cool box' or container with ice or freezer packs for transportation of milk.

CONCLUSION

A single document containing recommendations on all aspects of expressing, storing and transporting breast milk should be available for each unit, with the same basic information for mothers and the healthcare staff and further technical details for staff if required. The Sri Lankan recommendations need to be updated based on current worldwide practices and further studies are needed to establish a safe method of transport of expressed breast milk in Sri Lanka.

Food Safety Practices Linked with Proper Refrigerator Temperatures in Retail Delis

Listeria monocytogenes (L. monocytogenes) causes the third highest number of foodborne illness deaths annually. L. monocytogenes contamination of sliced deli meats at the retail level is a significant contributing factor to L. monocytogenes illness. The Centers for Disease Control and Prevention's Environmental Health Specialists Network (EHS-Net) conducted a study to learn more about retail delis' practices concerning L. monocytogenes growth and cross-contamination prevention. This article presents data from this study on the frequency with which retail deli refrigerator temperatures exceed 41°F, the Food and Drug Administration (FDA)-recommended maximum temperature for ready-to-eat food requiring time and temperature control for safety (TCS) (such as retail deli meat). This provision was designed to control bacterial growth in TCS foods. This article also presents data on deli and staff characteristics related to the frequency with which retail delis refrigerator temperatures exceed 41°F. Data from observations of 445 refrigerators in 245 delis showed that in 17.1% of delis, at least one refrigerator was >41°F. We also found that refrigeration temperatures reported in this study were lower than those reported in a related 2007 study. Delis with more than one refrigerator, that lacked refrigerator temperature recording, and had a manager who had never been food safety certified had greater odds of having a refrigerator temperature >41°F. The data from this study suggest that retail temperature control is improving over time. They also identify a food safety gap: some delis have refrigerator temperatures that exceed 41°F. We also found that two food safety interventions were related to better refrigerated storage practices: kitchen manager certification and recording refrigerated storage temperatures. Regulatory food safety programs and the retail industry may wish to consider encouraging or requiring kitchen manager certification and recording refrigerated storage temperatures.

On-farm storage of livestock vaccines may be a risk to vaccine efficacy: a study of the performance of on-farm refrigerators to maintain the correct storage temperature

BACKGROUND

Livestock vaccines (LV) are often stored on-farm, in a refrigerator (fridge), prior to use and little is documented about the storage conditions during this period. As the quality of a vaccine can be impaired by storage at an incorrect temperature, the present study aimed to evaluate the on-farm performance of farm fridges to maintain the correct storage temperature. From January to August 2014, temperature data loggers were placed on selected farms fridges used to store LV (n = 20) in South-West England.

RESULTS

Temperature recording data was available from 17 of the 20 farms. Fifty-nine percent of farm fridges had at least one temperature recording above 8 °C, 53% had at least one recording below 2 °C and 41% at or below 0 °C. Internal fridge temperatures attained 24 °C and dropped to - 12 °C as an absolute maximum and minimum respectively. Fridges tested spent an average of 16% of the total time recorded above 8 °C. Time of the year significantly influenced the percentage of time above 8 °C. External and internal temperatures were found to be positively correlated (p < 0.001). Statistical significant differences in internal and external temperatures were found between March and August.

CONCLUSIONS

The majority of fridges in this study would have failed to keep any stored LV within the recommended storage temperature range. If LV are going to be stored on-farm prior to use, then urgent improvements in this part of the cold-chain are required in order to insure vaccine efficacy is not compromised.

Status of cold chain in routine immunisation centres of the Expanded Programme on Immunisation in Quetta, Pakistan

OBJECTIVE

To determine the status of cold chain and knowledge and practices of health workers about cold chain maintenance in routine immunisation health centres.

METHODS

This cross-sectional study was conducted in Quetta, Pakistan, from May to July 2012, and comprised health facilities in the district. We interviewed the staff responsible for vaccine storage and cold chain maintenance and used a checklist to assess cold chain maintenance of routine expanded programme on immunisation vaccines. SPSS 16 was used for data analysis..

RESULTS

Of the 42 health facilities, staff of 13(30%) wrongly indicated that measles and Bacillus Calmette-Guérin were cold sensitive vaccines. Temperature of the ice-lined refrigerators was not maintained twice daily in 18(43%) centres. There were no voltage stabilisers and standby power generators in 31(74%) and 38(90%) centres, respectively. Vaccine arrangement was found to be inappropriate in ice-lined refrigerators of 38(90%) centres and ice packs were incorrectly used in carriers in 22(52%) centres. Vaccine stock was not charted in 39(93%) centres. Moreover, 4(10%) facilities did not have dedicated expanded programme on immunisation rooms whereas about 5(12%) and 33(79%) had no vaccinator and separate expanded programme on immunisation incharge appointed. Also, 32(76%) centres did not have a female vaccinator appointed.

CONCLUSIONS

Although the majority of health staff had adequate knowledge, there were weaknesses in practice of maintaining the cold chain.

Stability of Vancomycin in Icodextrin Peritoneal Dialysis Solution

Background:

Icodextrin is a glucose polymer used as an alternative osmotic agent in peritoneal dialysis (PD) solutions. There are few data regarding the long-term stability of vancomycin in icodextrin PD solution.

Objective:

To determine the chemical stability of vancomycin in icodextrin PD solution in polyvinyl chloride containers over a 7 day period at 4, 24, and 37 °C.

Methods:

Study samples were prepared by adding 2000 mg vancomycin HCl to commercially available 2.0 L bags of icodextrin 7.5% PD solution. Nine bags were prepared and stored in the following conditions: 3 under refrigeration (5 °C), 3 at room temperature (24 °C), and 3 at body temperature (37 °C). Samples were withdrawn from each bag immediately after preparation and at predetermined intervals over the subsequent 7 days. Solutions were visually inspected for precipitation, cloudiness, or discoloration at each sampling interval. Total concentration of vancomycin in dialysate fluid was determined by high performance liquid chromatography.

Results:

Under refrigeration, a mean ± SD of 99.7% ± 0.5% of the initial vancomycin concentration remained at 168 hours (7 days). At room temperature, 97.5% ± 3.4% remained at 168 hours. At body temperature, 94.3% ± 3.9% remained at 24 hours. Stability was not assessed beyond these time points.

Conclusions:

Premixed vancomycin-icodextrin PD solutions, whether stored refrigerated or at room temperature, were found to be stable for up to 7 days. However, we recommend that these solutions be kept refrigerated whenever possible. Solutions stored at body temperature were stable for up to 24 hours, permitting the practice of prewarming solutions prior to administration.

Knowledge and Practice of ANMs regardiiig Cold; Chain Management for Different Categories of Vaccines

A cold chain is a temperature-controlled supply chain. An unbroken cold chain is an uninterrupted series of storage and distribution activities which maintains a given temperature chain. It can be managed by the Quality Management System. It analyses, measuires, controls, documents the supply of vaccines to the reaching point. As a cold chain handler ANMs play an important role in improving the immunisation coverage. In a study, Samant Y, et al (2007) revealed weaknesses in the cold chain mechanism. Cold chain for the oral polio vaccine (OPV) was not adequately managed at primary and sub-health centres in rural areas. In India, at grass root level ANMs are the key persons, who handle the vaccine and equipment. So it was necessary to assess their knowledge and practices about management of cold chain system. Sufficient cold chain space is available at the district and block level. Some PHCs do not have electrical cold chain equipments. Although the breakdown rate is very low for existing cold chain equipments, yet cold chain management is not followed as per prescribed guidelines. Thus, necessary action can be taken for effective management of cold chain to ensure that the children get potent vaccines and are protected from the vaccine-preventable diseases. The management ofcold chain system is the most important component ofimmunisation on which success ofthe programme depends.

[The EFS metrology: From the production to the reason]

In order to answer statutory requirements and to anticipate the future needs and standards, the EFS is committed, since a few years, in a process of harmonization of its metrology function. In particular, the institution has opted for the skills development by internalizing the metrological traceability of the main critical quantities (temperature, volumetric) measurements. The development of metrology so resulted in a significant increase in calibration and testing activities. Methods are homogenized and improved through accreditations. The investment strategies are based on more and more demanding specifications. The performance of the equipments is better known and mastered. Technical expertise and maturity of the national metrology function today are assets to review in more informed ways the appropriateness of the applied periodicities. Analysis of numerous information and data in the calibration and testing reports could be pooled and operated on behalf of the unique establishment. The objective of this article is to illustrate these reflections with a few examples from of a feedback of the EFS Pyrénées Méditerranée. The analysis of some methods of qualification, the exploitation of the historical metrology in order to quantify the risk of non-compliance, and to adapt the control strategy, analysis of the criticality of an instrument in a measurement process, risk analyses are tools that deserve to be more widely exploited for that discipline wins in efficiency at the national level.

The use of telemedicine in Italian Blood Banks: a nationwide survey

BACKGROUND

Telemedicine is defined as the use of electronic information and communication technologies to provide health care between distant people. Many activities in transfusion medicine could benefit from the application of telemedicine. To map the spread of the use of telemedicine in transfusion medicine in Italy, the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) performed a nationwide survey: the results are presented in this paper.

MATERIALS AND METHODS

A survey, dealing with different aspects of the use of telemedicine, was performed by sending a questionnaire to 280 Italian Blood Centres. The survey was designed to evaluate the diffusion of telemedicine and the features of the systems, with special attention to the systems' safety and legal adequacy. One section of the questionnaire was designed to identify the features of the systems considered essential by the respondents.

RESULTS

Out of 280 Blood Services contacted, 196 (70%) filled in at least one of the questions of the online questionnaire. Globally the use of some form of telemedicine was reported by 70% of the respondents. Telemedicine is used for remote validation of laboratory tests by 32% of the Centres that responded, for remote biological validation of blood units by 34% and for assignment of blood components by 29%. Less frequently, telemedicine is used to control electronic refrigerators, for electronic blood requests and for bed-side identification of patients.

DISCUSSION

The use of telemedicine is widespread in Italian Blood Services. There appears to be some heterogeneity between structures with regards to the evaluation of the systems' safety and their legal adequacy. No telemedicine system should be introduced into practice until it has proven to have the same standards of safety as the corresponding "on site" activity.

Growth and inactivation of Salmonella at low refrigerated storage temperatures and thermal inactivation on raw chicken meat and laboratory media: mixed effect meta-analysis

Growth and inactivation regression equations were developed to describe the effects of temperature on Salmonella concentration on chicken meat for refrigerated temperatures (⩽10 °C) and for thermal treatment temperatures (55–70 °C). The main objectives were: (i) to compare Salmonella growth/inactivation in chicken meat versus laboratory media; (ii) to create regression equations to estimate Salmonella growth in chicken meat that can be used in quantitative risk assessment (QRA) modeling; and (iii) to create regression equations to estimate D-values needed to inactivate Salmonella in chicken meat. A systematic approach was used to identify the articles, critically appraise them, and pool outcomes across studies. Growth represented in density (Log₁₀ CFU/g) and D-values (min) as a function of temperature were modeled using hierarchical mixed effects regression models. The current meta-analysis analysis found a significant difference (P ⩽ 0.05) between the two matrices – chicken meat and laboratory media – for both growth at refrigerated temperatures and inactivation by thermal treatment. Growth and inactivation were significantly influenced by temperature after controlling for other variables; however, no consistent pattern in growth was found. Validation of growth and inactivation equations against data not used in their development is needed.

[The quality of immunization services in community centers in Abidjan, Côte d'Ivoire]

In addition to health care centers, other institutions such as community centers are also involved in providing immunization services, the purpose being to address the inadequate provision of services in this area. The purpose of this study was to assess the quality of immunization services provided by non-medical staff. A cross-sectional descriptive study was conducted over the course of two months in the 15 public community centers providing immunization services in Abidjan. Data collection was performed by two physicians using three questionnaires (one for center managers, one for vaccinators and one for vaccine recipients) and two observation checklists (to assess vaccination equipment and to observe the behaviors and practices of vaccinators). The study found that none of the centers had a generator. One community center had no refrigerator. Refrigerators were not placed in a ventilated area in 14.3 % of the centers and were not exclusively used for the storage of vaccines in 26.7 % of the centers. None of the centers had an incinerator. 21.1 % of staff did not know the correct storage temperature. In 88.9 % of cases, the swab used to stop bleeding was also used to clean the injection site. The injection site was not sterilized in 10.8 % of cases. 73.9 % of the recipients did not know what vaccine they had been administered, while 95 % of the recipients did not know the date of their next vaccination appointment. The results indicate that immunization services in public community centers have many shortcomings. To address these issues, it is necessary to implement a training policy and to provide appropriate equipment and supervision.

Assessing cold chain status in a metro city of India: an intervention study

BACKGROUND

Cold chain maintenance is an essential activity to maintain the potency of vaccines and to prevent adverse events following immunization. One baseline study highlighted the unsatisfactory cold chain status in city of Kolkata in India.

OBJECTIVES

To assess the changes which occurred in the cold chain status after the intervention undertaken to improve the status and also to assess the awareness of the cold chain handlers regarding cold chain maintenance.

METHODS

Intervention consisted of reorganization of cold chain points and training of health manpower in Kolkata Municipal area regarding immunization and cold chain following the guidelines as laid by Govt of India. Reevaluation of cold chain status was done at 20 institutions selected by stratified systematic random sampling after the intervention. The results were compared with baseline survey.

RESULTS

Significant improvement had been observed in correct placing of cold chain equipment, maintenance of stock security, orderly placing of ice packs, diluents and vaccines inside the equipment, temperature recording and maintenance. But awareness and skill of cold chain handlers regarding basics of cold chain maintenance was not satisfactory.

CONCLUSIONS

The success of intervention included significant improvement of cold chain status including creation of a designated cold chain handler. The gaps lay in non-availability of non-electrical cold chain equipment and separate cold chain room, policy makers should stress. Cold chain handlers need reorientation training regarding heat & cold sensitive vaccines, preventive maintenance and correct contingency plan.

Comparing cooling systems for the COBE 2991 cell separator used in the purification of human pancreatic islets of Langerhans

Two different approaches of controlled cooling of the COBE 2991 cell-separator for islet purification were evaluated. The first method is the new Geneva COBE cooling system (GCCS), which consists of an electronically controlled liquid nitrogen injection system. The second is the University of Illinois at Chicago cooling system (UICCS), which consists of a specially designed "Cold Room" maintained at 1-8 C. For the GCCS, the mean temperatures of the gradient solutions were measured at the beginning and end of centrifugation were found to be 7 +/-0.7 C and 6.8 +/-0.6 C respectively. For the UICCS, the mean temperature of the gradients at the beginning and end of centrifugation were 4.7 +/-0.53 C and 7.03 C+/-0.91 C respectively. The presented COBE cooling systems can easily be adapted to a COBE 2991 cell-separator and are efficient in maintaining gradient solutions at a defined low temperature during centrifugation.

Use of cool water packs to prevent freezing during vaccine transportation at the country level

OBJECTIVES

To study the impact of the use of cool water packs (water packs refrigerated at 2 to 8 degrees C) on the cold life of vaccine transport boxes and the shelf life of the vaccines.

METHODS

Data loggers were used to measure the temperatures of vaccine shipments with cool water packs in laboratory studies and country evaluations. The temperature recordings were mathematically translated into reduction of vaccines shelf life, which are illustrated through degrees of color changes of Vaccine Vial Monitors.

FINDINGS

Laboratory studies at extreme ambient temperatures (43 degrees C) showed that, with the use of cool water packs, temperatures inside the cold box rise to around 20 degrees C within 48 h. When this exposure scenario was repeated four times, the impact of the temperature history on the different heat stability categories of vaccines varied between 2.4 and 36.0% shelf life loss. Oral polio vaccine was found to be the most affected vaccine. All other vaccines were affected with 2.4 to 10.4% life loss. Country assessments (real life situation with temperature variations between day and night) showed between 0.4% to 4.6% life loss when the boxes were exposed to ambient temperatures ranging from 11.7 to 39.8 degrees C over the 98 h 15 min test period.

CONCLUSIONS

The use of cool water packs is found to be a legitimate and safe practice for vaccines other than oral polio vaccine, so that cool water packs can safely replace frozen icepacks without any serious consequences on the ability of vaccines to confer protection against disease.

Transfusion management using a remote-controlled, automated blood storage

BACKGROUND

Generally, the safety of transfusion terapies for patients depends in part on the distribution of the blood products. The prevention of adverse events can be aided by technological means, which, besides improving the traceability of the process, make errors less likely. In this context, the latest frontier in automation and computerisation is the remote-controlled, automated refrigerator for blood storage.

MATERIALS AND METHODS

Computer cross-matching is an efficient and safe method for assigning blood components, based on Information Technology applied to typing and screening. This method can be extended to the management of an automated blood refrigerator, the programme of which is interfaced with the Transfusion Service's information system. The connection we made in our Service between EmoNet and Hemosafe enables real-time, remote-controlled management of the following aspects of blood component distribution: a) release of autologous and allogeneic units already allocated to a patient, b) release of available units, which can be allocated by remote-control to known patients, in the presence of a valid computer cross-match, c) release of O-negative units of blood for emergencies.

RESULTS

Our system combines an information database, which enables computer cross-matching, with an automated refrigerator for blood storage with controlled access managed remotely by the Transfusion Service. The effectiveness and safety of the system were validated during the 4 months of its routine use in the Transfusion Service's outpatient department.

CONCLUSIONS

The safety and efficiency of the distribution of blood products can and must be increased by the use of technological innovations. With the EmoNet/Hemosafe system, the responsibility for the remote-controlled distribution of red blood cell concentrates remains with the chief of the Transfusion Services, through the use of automated computer procedures and supported by continuous training of technicians and nursing staff.

Status of cold-chain maintenance in Chandigarh

An effective cold chain maintenance system is the backbone of success of any immunization program. This study compares the state of cold chain maintenance during intensive pulse polio immunization campaign in union territory of Chandigarh in the year 2001 with that of 2006. The study was conducted during pulse polio rounds of December 2001 and January 2002 and another in April and May 2006 by Department of Community Medicine, Govt. Medical College, Chandigarh. Data was collected from different levels of cold chain maintenance; OPV vials were also collected and sent for potency testing at Central Research Institute, Kasauli in all the rounds. Cold chain sickness rate has decreased from 9.8% in year 2001 to 6% in year 2006. Icepacks were neatly stacked in all the deep freezers (DF) and ice-lined refrigerators (ILR). 94.71% DF's & ILR's were defrosted periodically, 95.36% temperature charts were up-to-date and signed by supervisors and no day carriers were being used in 2006 round. Whereas in 2001, the periodicity of defrosting ILR & DFs was 76.9%, vaccines were stacked neatly in only 38.46% and day carriers were being used. All the randomly selected vaccine samples were reported potent.

Training needs for mid-level managers and immunisation coverage in Western Kenya

OBJECTIVES

To determine the current status of immunisation coverage in Western Kenya before intervention, to identify strengths and weaknesses of the existing programme in order to design educational interventions that could improve the services provided and find out the training needs of the mid-level managers of Kenya Expanded Programme of Immunisation.

DESIGN

Cross-sectional descriptive study.

SETTING

All thirty nine districts in Rift Valley, Western and Nyanza provinces.

SUBJECTS

Mid-level managers of Kenya Expanded Programme on Immunisation in the 39 districts and the provinces. These included Provincial Logisticians, Provincial Medical Officers of Health, District Medical Officers of Health, District Public Health Nurses, District Records and Health Information Officers, District Disease Surveillance Officers, and District Public Health Officers.

MAIN OUTCOME MEASURES

Number of staff trained on EPI, coverage rates and perceived training needs of the mid-level managers.

RESULTS

A total of eighty eight mid-level managers participated in the interviews. Most of these were District Public Health Nurses (40.9%) and District Health Information and Records Officers (23.9%). Only 49 (25%) of the District Health Management Team members had undergone training at the supervisory level. Eighteen districts (43.6%) had no member of the District Health Management Team that had ever been trained at the supervisory level. Using rates of Pentavalent 1 and measles coverage, Nyanza Province had the highest immunisation dropout rate (Pentavalent 1--measles) whereas Rift Valley Province had the lowest. The annual cumulative coverage for all the provinces by antigen was 80% for Pentavalent 1 and 2 and 60% for measles. The most requested need for inclusion in the training curriculum was maintenance of the cold chain equipment.

CONCLUSIONS

Most of the members in the study area have not been trained on Expanded Programme on Immunisation and may be ill-equipped to manage the complicated programmes needed to maximise delivery of services. The immunisation coverage in this area is low while the dropout rates are high. We therefore recommend that all the mid-level managers of Expanded Programme on Immunisation in this area be trained comprehensively through the Merck Vaccine Network--Africa programme using the World Health Organisation approved mid-level managers course.

Room-temperature storage of medications labeled for refrigeration

PURPOSE

Data regarding the recommended maximum duration that refrigerated medications available in hospital pharmacies may be stored safely at room temperature were collected and compiled in a tabular format.

METHODS

During May and June of 2006, the prescribing information for medications labeled for refrigeration as obtained from the supplier were reviewed for data addressing room-temperature storage. Telephone surveys of the products' manufacturers were conducted when this information was not available in the prescribing information. Medications were included in the review if they were labeled to be stored at 2-8 degrees C and purchased by the pharmacy department for uses indicated on the hospital formulary. Frozen antibiotics thawed in the refrigerator and extemporaneously compounded medications were excluded. Information was compiled and arranged in tabular format. The U.S. Pharmacopeia's definition of room temperature (20-25 degrees C [68-77 degrees F]) was used for this review.

RESULTS

Of the 189 medications listed in AHFS Drug Information 2006 for storage in a refrigerator, 89 were present in the pharmacy department's refrigerator. Since six manufacturers were unable to provide information for 10 medications, only 79 medications were included in the review. This table may help to avoid unnecessary drug loss and expenditures due to improper storage temperatures.

CONCLUSION

Information regarding the room-temperature storage of 79 medications labeled for refrigerated storage was compiled.

Mantenimiento de la cadena del frío para las vacunas: una revisión sistemática

OBJECTIVE

Systematic immunization programmes mostly depend on the correct maintenance and manipulation of the vaccines to be used, i.e. perfect maintenance of the cold chain. Therefore, we decided to carry out a systematic review of the literature on the cold chain and vaccines, to identify daily practices in vaccine sites.

METHODS

A literature search was performed in the main medical databases for documents published between 1990 and 2005, including those performed by means of a survey and/or inspection of vaccine sites that provided the following data: a designated health officer, availability of a thermometer with maximums and minimums, refrigerator temperature at the time of the visit, and temperature control and registration. For all the variables, the mean prevalence was calculated with a 95% confidence interval.

RESULTS

Three hundred seventy-seven articles were found; 31 were initially selected and 13 were finally included. In 72.21% of the vaccine points, there was an officer responsible for the vaccines, but only 61.43% knew the optimal temperature range. Fifty-five percent of these points had a thermometer with maximums and minimums and only 26.88% carried out temperature controls and registrations at least once per day.

CONCLUSION

Important shortfalls were detected in cold chain maintenance in all selected articles, jeopardizing the effectiveness and efficiency of immunization programs.

Consumer home refrigeration practices: results of a web-based survey

To reduce bacterial growth and to ensure the quality and safety of food products, the U.S. Department of Agriculture and the U.S. Food and Drug Administration advise consumers to clean their refrigerators regularly, use a refrigerator thermometer, and keep refrigerator temperatures at 40 degrees F (4.4 degrees C) or below. We conducted a nationally representative Web-enabled survey (n = 2,060) to collect data on refrigerator thermometer ownership, home refrigerator temperatures, and the frequency of home refrigerator cleaning. We stratified the sample to provide results for pregnant women, older adults (60 years or older), and the remaining population. About half of all respondents had cleaned their refrigerators at least 1 month before the survey. Only 11% of all respondents had a thermometer in their refrigerator before the survey. Older adults (77.5%) were more likely than the remaining population (70.4%) to have their refrigerators at the recommended temperature (P < 0.01). Older adults who were not married and who lived alone were less likely to have refrigerator thermometers and to have their refrigerators at a recommended temperature (P < 0.05). For all respondents, those who had previously owned a refrigerator thermometer were more likely to have their refrigerators at the recommended temperature than were respondents who did not previously own a thermometer (P < 0.01). Food safety educators can use the survey findings and results of previous research to target educational materials and help consumers, especially those at risk for listeriosis, to safely store refrigerated foods at home.

Comparison of the safety and immunogenicity of a refrigerator-stable versus a frozen formulation of ProQuad (measles, mumps, rubella, and varicella virus vaccine live)

OBJECTIVE

A refrigerator-stable formulation of ProQuad has been developed to expand the utility of ProQuad to areas in which maintenance of a frozen cold chain (-15 degrees C or colder) during storage and transport may not be feasible. The objective of this study was to demonstrate that the immunogenicity and safety profiles of a refrigerator-stable formulation of ProQuad are similar to the recently licensed frozen formulation.

METHODS

In this double-blind, randomized, multicenter study, healthy 12- to 23-month-old children with negative vaccination and clinical histories for measles, mumps, rubella, varicella, and zoster were vaccinated with either the refrigerator-stable formulation of ProQuad (N = 1006) or the frozen formulation of ProQuad (N = 513). Patients were followed for 42 days after vaccination for adverse experiences. Immunogenicity was evaluated 6 weeks after vaccination.

RESULTS

The refrigerator-stable formulation of ProQuad was generally well tolerated. The incidence of adverse experiences was similar between groups. No vaccine-related serious adverse experiences were reported. For both groups, the response rate was > or = 97.7% for measles, mumps, and rubella, and the percentage of patients with a varicella zoster virus antibody titer of > or = 5 U/mL glycoprotein antigen-based enzyme-linked immunosorbent assay after vaccination was > or = 88.8%. The geometric mean titers for all antigens were numerically slightly higher in patients who received the refrigerator-stable formulation.

CONCLUSIONS

The refrigerator-stable formulation of ProQuad is generally well tolerated, highly immunogenic, and noninferior in terms of postvaccination antibody responses. This refrigerator-stable formulation may improve ease of vaccine administration, increase use of the vaccine throughout the world because of its improved storage conditions, and replace the frozen formulation of ProQuad or any dose of M-M-RII and Varivax in routine practice.

Home-Prepared Saline

OBJECTIVE

The purpose of this study was to determine (1) the rate of contamination for a normal saline solution prepared with distilled water and salt when stored at room temperature and (2) when stored under refrigerated conditions; and (3) to compare the rate of contamination for solutions prepared and stored under controlled conditions with those prepared and stored in patients' homes.

DESIGN

This quasi-experimental study examined the bacterial content of saline made with distilled water and stored at room temperature and that of saline stored in a refrigerator.

SETTING

A large urban home health agency was the setting for the study.

METHODS

Eight teaspoons of table salt were added to 1-gallon jugs of distilled water purchased from a grocery store to produce a normal saline solution. Two gallons of the prepared solution were stored at room temperature (80 degrees F) and 2 were stored in a refrigerator (48 degrees F). Cultures were taken from each of the 4 bottles of prepared solution immediately following preparation and at weekly intervals until bacterial growth occurred, or 4 weeks after preparation.

RESULTS

All tested solutions were negative for bacterial growth at baseline. Cultures of the solution stored at room temperature were positive for bacterial growth 2 weeks after preparation, whereas those stored under refrigerated conditions remained free of bacterial contamination 4 weeks after preparation. Two "patient-prepared" solutions were tested at 3 weeks, and both were negative for bacteria at that time. Three patient-prepared solutions were tested at 4 weeks, of which 2 showed no bacterial growth in 48 hours, whereas 1 revealed 600 cfu/mL of Pseudomonas species.

CONCLUSIONS

The results of this small study suggest that saline solutions produced by adding table salt to distilled water will remain bacteria-free for 1 month if refrigerated. Additional studies are needed to confirm these findings.

Detection and Characterization of Listeria monocytogenes in São Jorge (Portugal) Cheese Production

Listeria monocytogenes is a foodborne pathogen that can cause serious invasive disease in humans. Because human listeriosis cases have previously been linked to consumption of contaminated cheese, control of this pathogen throughout the cheese production chain is of particular concern. To understand the potential for L. monocytogenes transmission via São Jorge cheese, a Portuguese artisanal cheese variety that bears a Protected Denomination of Origin classification, 357 raw milk, curd, natural whey starter, and cheese samples representative of the production chain of this cheese were collected over one year and tested for the presence of L. monocytogenes and selected physicochemical parameters. Although neither L. monocytogenes nor other Listeria spp. were detected in whey, curd, or cheese samples, 2 of the 105 raw milk samples analyzed were positive for L. monocytogenes. These 2 raw milk isolates represented a ribotype that has previously been linked to multiple human listeriosis outbreaks and cases elsewhere, indicating the potential of these isolates to cause human listeriosis. On average, physicochemical parameters of São Jorge cheese ripened for 4 mo presented values that likely minimize the risk of L. monocytogenes outgrowth during ripening and storage (mean pH = 5.48; mean moisture = 37.79%; mean NaCl concentration = 4.73%). However, some cheese samples evaluated in this study were characterized by physicochemical parameters that may allow growth and survival of L. monocytogenes. Even though our results indicate that raw milk used for São Jorge cheese manufacture as well as finished products is rarely contaminated with L. monocytogenes, continued efforts to control the presence of this pathogen in the São Jorge cheese production chain are urged and are critical to ensure the safety of this product.

A vaccine cold chain freezing study in PNG highlights technology needs for hot climate countries

Fourteen data loggers were packed with vaccine vials at the national vaccine store, Port Moresby, Papua New Guinea (PNG), and sent to peripheral locations in the health system. The temperatures that the data loggers recorded during their passage along the cold chain indicated that heat damage was unlikely, but that all vials were exposed to freezing temperatures at some time. The commonest place where freezing conditions existed was during transport. The freezing conditions were likely induced by packing the vials too close to the ice packs that were themselves too cold, and with insufficient insulation between them. This situation was rectified and a repeat dispatch of data loggers demonstrated that the system had indeed been rectified. Avoiding freeze damage becomes even more important as the price of freeze-sensitive vaccines increases with the introduction of more multiple-antigen vaccines. This low-cost high-tech method of evaluating the cold chain function is highly recommended for developing and industrialized nations and should be used on a regular basis to check the integrity of the vaccine cold chain. The study highlights the need for technological solutions to avoid vaccine freezing, particularly in hot climate countries.

Stability of influenza sub-unit vaccineDoes a couple of days outside the refrigerator matter?

In this study 27 full scale production batches of influenza sub-unit vaccine were evaluated on their stability. The batches varied with respect to the strains they contained and regarding the presence of the preservative thiomersal in the solution. The stability study showed that haemagglutinin content was the most sensitive parameter. An increase in the storage temperature strongly increased the degradation rate of haemagglutinin. The degradation rate of the haemagglutinin differed for the different strains tested. However, statistical evaluation of the data obtained for the most sensitive strain tested showed that even exposure during a 2 week period of the vaccine to room temperature would not adversely affect the shelf life claim of the influenza subunit vaccine of 1 year in the refrigerator. Moreover, this study showed that the presence of thiomersal in the solution has no effect on the stability of the vaccine.

The key role of vaccine vial monitors in routine and mass immunisation

The vaccine vial monitor is an excellent monitoring device to assure that only non-heat damaged vaccine is administered to women and children. They help to extend access to immunisation, they increase the efficiency and reduce wastage in the cold-chain and, when visible on all vaccine vials of all types, they will help to streamline distribution systems for immunisation services of the 21st century in all developing countries.

Food safety knowledge of consumers and the microbiological and temperature status of their refrigerators

The objectives of this study were to examine domestic food safety knowledge levels of consumers, establish the levels and incidence of bacterial contamination and operational temperatures in domestic refrigerators, and identify areas in which consumer food safety education is necessary in Ireland. A food safety knowledge questionnaire applied to a representative sample of households (n = 1,020) throughout the island of Ireland found the gaps in consumer food safety knowledge. Analysis of swab samples (n = 900) recovered from the domestic refrigerators in these households showed average total viable counts of 7.1 log CFU/cm2 and average total coliform counts of 4.0 log CFU/cm2. Analysis of swab samples also detected the incidence of Staphylococcus aureus (41%), Escherichia coli (6%), Salmonella enterica (7%), Listeria monocytogenes (6%), and Yersinia enterocolitica (2%). Campylobacter jejuni and E. coli O157:H7 were not detected in domestic refrigerators. The temperature profiles of a subset of the sampled refrigerators (100) were monitored for 72 h, and 59% were found to operate, on average, at temperatures above the recommended 5 degrees C. Knowledge and temperature survey results varied considerably, but consumers who scored better in terms of basic food safety knowledge had reduced levels of bacterial contamination in their refrigerators and reported a reduced incidence of food-associated illnesses. This study confirms the effect of basic food hygiene knowledge on hygienic practice and identifies specific areasfor emphasis in the development and delivery of effective food safety risk communication messages to consumers.

Biological qualification of blood units: considerations about the effects of sample's handling and storage on stability of nucleic acids

BACKGROUND

In transfusional setting introduction of nucleic amplification technique (NAT) for HBV-DNA, HCV-RNA and HIV-RNA in biological qualification of blood units suggest some problems. At first the opportunity to operate on mini-pool, at second the need to store the samples at +4 degrees C. The authors therefore have tried to estimate the impact of these conditions on the operativity of NAT testing in the transfusional setting.

METHODS

The following parameters has been estimated: distribution of viral-load in untreated subjects, stability of nucleic acids during storage at +4 degrees C, stability of nucleic acids after repeated cycles of freezing and defrosting, robustness of the test to the cross-contamination, definition of the detection-limit (95%). Quantitative tests has been performed by using the following kits: Cobas Amplicor HBV Monitor, Cobas Amplicor HCV Monitor, Cobas Amplicor HIV Monitor; the qualitative tests has been performed by using the following kits: Ampliscreen HBV, Ampliscreen HCV 2,0, Ampliscreen HIV 1,5 all supplied by Roche Molecular System (Brancburg, NJ).

RESULTS

Viral load in untreated subjects showed wide variation for HBV, HCV and HIV. HBV has been demonstrated much stable to the conservation +4 degrees C also until 168 h while for HCV and HIV a greater decrease of the viral-load was observed. For all and three virus the conservation to +4 degrees C until 72 h does not seem to involve meaningful fall in the viral-load. A remarkable reduction of the viral-load has been observed after five cycles of freezing and defrosting. All the tests showed a good robustness to cross-contamination. The detection-limit (95%) was 8 U/ml for HBV, 21 U/ml for HCV and 27 copy/ml for HIV.

CONCLUSIONS

Samples for NAT testing, can be stored until 72 h to +4 degrees C without appreciable lowering of the viral-load. Repeated cycles of changes of state should be avoided. The tests showed a good robustness to cross-contamination. NAT tests for biological qualification of blood units had a minimal sensibility around 50 (copy/unit/ml). In our experience the detection-limit (95%) was 21 U/ml for HCV, 27 copies/ml for HIV, 8 U/ml for HBV. The availability of NAT test for HBV-DNA, HCV-RNA e HIV-RNA, sensitive and reliable, together with epidemiological data, suggest the opportunity to place side by side, in the biological qualification of the blood units, to add the tests for HBV-DNA and HIV-RNA to the test for HCV-RNA mandatory by low, in Italy in the biological qualification of blood units.

Home storage temperatures and consumer handling of refrigerated foods in Sweden

The lack of data on consumer refrigeration temperatures and storage times limits our ability to assess and manage risks associated with microbial hazards. This study addressed these limitations by collecting data on temperatures and storage handling practices of chilled foods. Consumers from 102 households in Uppsala, Sweden, were instructed to purchase seven food items (minced meat, fresh herring fillets, soft cheese, milk, sliced cooked ham, vacuum-packed smoked salmon, and ready-to-eat salad) and to store them using their normal practices. They were interviewed the next day, and food temperatures were measured. In general, there were no significant relations between temperature and characteristics of the respondents (e.g., sex, age, education, age of the refrigerator). Mean storage temperatures ranged from 6.2 degrees C for minced meat to 7.4 degrees C for ready-to-eat salad. Maximum temperatures ranged from 11.3 to 18.2 degrees C. Data were not significantly different from a normal distribution, except for ready-to-eat salad, although distributions other than the normal fitted data better in most cases. Five percent to 20% of the food items were stored at temperatures above 10 degrees C. Most respondents knew the recommended maximum temperature, but less than one fourth claimed to know the temperature in their own refrigerator. Practical considerations usually determined where food was stored. For products with a long shelf life, stated storage times were different for opened and unopened packages. The current situation might be improved if consumers could be persuaded to use a thermometer to keep track of refrigerator temperature.

A review of outbreaks of foodborne disease associated with passenger ships: evidence for risk management

OBJECTIVE

Foodborne disease outbreaks on ships are of concern because of their potentially serious health consequences for passengers and crew and high costs to the industry. The authors conducted a review of outbreaks of foodborne diseases associated with passenger ships in the framework of a World Health Organization project on setting guidelines for ship sanitation.

METHODS

The authors reviewed data on 50 outbreaks of foodborne disease associated with passenger ships. For each outbreak, data on pathogens/toxins, type of ship, factors contributing to outbreaks, mortality and morbidity, and food vehicles were collected.

RESULTS

The findings of this review show that the majority of reported outbreaks were associated with cruise ships and that almost 10,000 people were affected. Salmonella spp were most frequently associated with outbreaks. Foodborne outbreaks due to enterotoxigenic E. coli spp, Shigella spp, noroviruses (formally called Norwalk-like viruses), Vibrio spp, Staphylococcus aureus, Clostridium perfringens, Cyclospora sp, and Trichinella sp also occurred on ships. Factors associated with the outbreaks reviewed include inadequate temperature control, infected food handlers, contaminated raw ingredients, cross-contamination, inadequate heat treatment, and onshore excursions. Seafood was the most common food vehicle implicated in outbreaks.

CONCLUSIONS

Many ship-associated outbreaks could have been prevented if measures had been taken to ensure adequate temperature control, avoidance of cross-contamination, reliable food sources, adequate heat treatment, and exclusion of infected food handlers from work.

[Maintenance of cold chain for the delivery of immunobiological drugs by the indicators of heating and freezing controls]

The paper deals with an objective evaluation of a qualitative storage of immunobiological drugs including all stages of "cold chain". The results of technological research and of designing related with constructing a system of indicators for monitoring the temperature regime to maintain the "cold chain" functioning are presented. The suggested devices are comparatively described.