The immunisation cold chain. Why is it so hard to get right?

BACKGROUND

Although the standards for vaccine storage required for accreditation of general practices, and the Guidelines for Australian Immunisation are widely available, all research to date suggests that in Australia compliance with these standards has not been readily achieved.

OBJECTIVE

The New South Wales Central West Division of General Practice (NSWCWDGP) and the Public Health Unit of the New South Wales Mid Western Area Health Service (NSW MWAHS) worked together from 1999 to 2001 to produce an intervention that would gather information about current vaccine storage, and provide practical help to storage sites which were not complying with accepted standards.

DISCUSSION

Cooperation between a general practice division and the public health unit can deliver coverage of 100% of vaccinators in a large geographic region. We have demonstrated that the lack of a designated person to take on ultimate responsibility for vaccines at a site is associated with less chance of achieving safe storage. Persistent difficulty in 'getting it right' has been documented. One new measure we have suggested and trialled is the installation of affordable commercial thermostats in the domestic refrigerators that are now widely used. Another is the piloting of a general practice division administered mailout program of temperature dataloggers to document the ongoing compliance of vaccine storage sites with accepted standards.

[Harmonization criteria for inspection procedures. Italian Group for Quality Assurance in Research]

In order to achieve higher levels of harmonisation for the application of the principles of good laboratory practice (GLP), the monitoring Authority has set up for the inspectors some guidelines to conduct inspections, as approved by the National co-ordination committee. The extension of these guidelines should allow for an improved application of the GLP principles taking into account actual situations detected during inspections carried out over the past years. In this respect a great number of observations formulated by the inspectors after inspecting several test facilities have been examined without revealing laboratories' and inspectors' identities. In addition to this, the observations made by the inspectors during the annual training course at the Istituto Superiore di Sanità in 2000 have been carefully considered.

[Technical problems associated with the cold chain]

After having covered the current status of the cold chain in France, the author highlights the economic impact of refrigerated storage and processing involving refrigeration. Lose reduction is such that the return on investments is estimated as being roughly 3 years. In years to come, progress will be achieved in the field of plant design. Some information on design trends is provided. Operators in general, and carriers in particular, are faced with an increasingly complex regulatory framework leading to a competition imbalance. The current cold chain developmental trend is characterized by complex computer management of logistics: the flow of goods is modulated in order to meet the production to the distribution needs as cost effectively as possible. This logistic strategy enables management of downstream to upstream interfaces involving various operators. Finally, the author indicates the main causes of non-compliance with the cold chain, generally at retail and consumer levels.

Effect of storage temperature on endogenous GHB levels in urine

Because gamma-hydroxybutyrate (GHB) is an endogenous substance present in the body and is rapidly eliminated after ingestion, toxicologists investigating drug-facilitated sexual assault cases are often asked to differentiate between endogenous and exogenous levels of GHB in urine samples. This study was designed to determine the effects of storage temperature on endogenous GHB levels in urine. Specifically, it was designed to ascertain whether endogenous levels can be elevated to a range considered indicative of GHB ingestion. Urine specimens from two subjects that had not been administered exogenous GHB were collected during a 24h period and individually pooled. The pooled specimens were separated into standard sample cups and divided into three storage groups: room temperature ( approximately 25 degrees C), refrigerated (5 degrees C), and frozen (-10 degrees C). Additionally, some specimens were put through numerous freeze/thaw cycles to mimic situations that may occur if multiple laboratories analyze the same specimen. Periodic analysis of the samples revealed increases in the levels of endogenous GHB over a 6-month period. The greatest increase (up to 404%) was observed in the samples maintained at room temperature. The refrigerated specimens showed increases of 140-208%, while the frozen specimens showed smaller changes (88-116%). The specimens subjected to multiple freeze/thaw cycles mirrored specimens that had been thawed only once. None of the stored urine specimens demonstrated increases in GHB concentrations that would be consistent with exogenous GHB ingestion.

Pseudo-outbreak of Mycobacterium gordonae associated with water from refrigerated fountains

Between March 1997 and December 1997, acid-fast bacilli (AFB) were detected on sputum and/or gastric aspirates smears from five patients hospitalized in the chest medicine department. These specimens grew M. gordonae. Based on AFB-positive smear and clinical presentation, four out of five patients received antituberculous treatment until species identification was known. Epidemiological investigation revealed a heavy contamination of water collected from refrigerated fountains located on the same floor as the patient cases. Strains isolated from four patients and the refrigerated fountain exhibited the same pulsed gel electrophoresis pattern (using DraI and XbaI enzymes) suggesting that positive smears were related to drinking water from the refrigerated fountain. This cluster of pseudo-infections underlines the necessity for a proper maintenance of water supply equipment in order to avoid inappropriate decisions deleterious for patients.

Risk factors for improper vaccine storage and handling in private provider offices

CONTEXT

Preventing loss of vaccine potency during storage and handling is increasingly important as new, more expensive vaccines are introduced, in at least 1 case requiring a different approach to storage. Little information is available about the extent to which staff in private physicians' offices meet quality assurance needs for vaccines or have the necessary equipment. Although the National Immunization Program at the Centers for Disease Control and Prevention (CDC) in 1997 developed a draft manual to promote reliable vaccine storage and to supplement published information already available from the CDC and the American Academy of Pediatrics, the best ways to improve vaccine storage and handling have not been defined.

OBJECTIVES

To estimate the statewide prevalence of offices with suboptimal storage and handling, to identify the risk factors for suboptimal situations in the offices of private physicians, and to evaluate whether the distribution of a new National Immunization Program draft manual improved storage and handling practices.

DESIGN

Population-based survey, including site visits to a stratified, random sample of consenting private physicians' offices. At least 2 months before the site visits, nearly half (intervention group) of the offices were randomly selected to receive a draft CDC manual entitled, "Guideline for Vaccine Storage and Handling." The remainder was considered the control group. Trained graduate students conducted site visits, all being blinded to whether offices were in the intervention or control groups. Each site visit included measurements of refrigerator and freezer temperatures with digital thermometers (Digi-thermo, Model 15-077-8B, Control Company, Friendswood, TX; specified accuracy +/- 1 degrees C). Their metal-tipped probes were left in the center shelf of cold storage compartments for at least 20 minutes to allow them to stabilize. The type of refrigerator/freezer unit, temperature-monitoring equipment, and records were noted, as were the locations of vaccines in refrigerator and freezer, and the presence of expired vaccines. Other information collected included the following: staff training, use of written guidelines, receipt of vaccine deliveries, management of problems, number of patients, type of office, type of medical specialty, and the professional educational level of the individual designated as vaccine coordinator.

PARTICIPANTS

Two hundred twenty-one private physicians' offices known by the Georgia Immunization Program in 1997 to immunize children routinely with government-provided vaccines.

OUTCOME MEASURES

Estimates (prevalence, 95% confidence interval [CI]) of immunization sites found to have a suboptimally stored vaccine at a single point in time, defined as: vaccine past expiration date, at a temperature of </=1 degrees C or >/=9 degrees C in a refrigerator or >/=-14 degrees C (recommended for varicella vaccine) in freezer, and odds ratios (ORs) for risk factors associated with outcomes. We performed chi(2) analysis and Student's t tests to compare the administrative characteristics and quality assurance practices of offices with optimal vaccine storage with those with suboptimal storage, and to compare the proportion of offices with suboptimal storage practices in the groups that did and did not receive the CDC manual.

RESULTS

Statewide estimates of offices with at least 1 type of suboptimal vaccine storage included: freezer temperatures measuring >/=-14 degrees C = 17% (95% CI: 10.98, 23.06); offices with refrigerator temperatures >/=9 degrees C = 4.5% (95% CI: 1.08, 7.86); offices with expired vaccines = 9% (95% CI: 4.51, 13.37); and offices with at least 1 documented storage problem, 44% (95% CI: 35.79, 51.23). Major risk factors associated with vaccine storage outside recommended temperature ranges were: lack of thermometer in freezer (OR: 7.15; 95% CI: 3.46, 14.60); use of freezer compartment in small cold storage units (OR: 5.46; 95% CI = 2.70, 10.99); lack of thermometer in refrigerator (OR: 3.07; 95% CI: 1.15,8.20); and failure to maintain temperature log of freezer (OR: 2.70; 95% CI: 1.40, 5.23). Offices that adhered to daily temperature monitoring for all vaccine cold storage compartments, compared with those that did not, were 2 to 3 times more likely to assign this task to staff with higher levels of training, have received a recent visit from the state immunization program, and be affiliated with a hospital or have Federally Qualified Health Center status. In addition, sites using >1 refrigerator/freezer for vaccine storage were more likely to have at least 1 cold storage compartment outside recommended temperature ranges. We found no significant differences in the data reported above between the intervention group (received copy of the draft manual) and the control group (did not receive copy of draft manual), even when controlling for the annual number of immunizations given or the type of office. (ABSTRACT TRUNCATED)

Microbiological quality and safety of quahog clams, Mercenaria mercenaria, during refrigeration and at elevated storage temperatures

The effects of storage temperatures and times on the microbiological quality and safety of hard-shelled quahog clams (Mercenaria mercenaria) were examined. Samples were stored at four different incubation temperatures (3.3, 7.2, 10.0, and 12.8 degrees C) for a period of 3 weeks, following their harvest from summer growing waters (> or = 27 degrees C) and winter waters (< or = 4 degrees C). Clams were analyzed for two naturally occurring pathogens, Vibrio parahaemolyticus and Vibrio vulnificus. During the summer, V. parahaemolyticus was isolated from 56% of the stored samples, with the highest concentration, 6,100/g, occurring on day 12 at 12.8 degrees C. Also, during the summer, V. vulnificus was isolated from 11% of the stored samples, with the highest concentration of 1,500/g occurring on day 15 at 7.2 degrees C. No Vibrio spp. were detected during the winter. During summer storage, aerobic mesophilic counts on plate count agar (PCA) containing 2% NaCl ranged from 10(4) to 10(8) CFU/g, and during storage of the winter samples, aerobic mesophilic PCA (with added NaCl) counts ranged from <100 to 10(4) CFU/g. Comparatively, summer storage mesophilic counts on PCA containing no added NaCl ranged from <100 to 10(5) CFU/g, and for the winter samples the range was <100 to 10(2) CFU/g. Coliform and fecal coliform counts ranged from <0.3 to 61.1/g and <0.3 to 24.4/g, respectively. There was no statistical correlation between the length of storage or the temperature of incubation and the presence of V. parahaemolyticus, V. vulnificus, coliforms, or fecal coliforms. However, storage time and incubation temperature affected the PCA counts (P < or = 0.05) in quahog clams.

Food labeling, safe handling statements, labeling of shell eggs; refrigeration of shell eggs held for retail distribution. Food and Drug Administration, HHS. Final rule

The Food and Drug Administration (FDA) is revising its food labeling regulations to require a safe handling statement on cartons of shell eggs that have not been treated to destroy Salmonella microorganisms. The agency also is requiring that, when held at retail establishments, shell eggs be stored and displayed under refrigeration at a temperature of 7.2 degrees C (45 degrees F) or less. FDA is taking these actions because of the number of outbreaks of foodborne illnesses and deaths caused by Salmonella Enteritidis (SE) that are associated with the consumption of shell eggs. These actions also respond, in part, to petitions from Rose Acres Farm, Inc., and the Center for Science in the Public Interest (CSPI). Safe handling statements will help consumers take measures to protect themselves from illness or deaths associated with consumption of shell eggs that have not been treated to destroy Salmonella (all serotypes). Refrigeration of shell eggs that have not been treated to destroy Salmonella will help prevent the growth of SE in shell eggs.

[HACCP (Hazard Analysis and Critical Point system) at a catering service: checklist and microbiological examination]

The A.A. carried out a survey on the functioning of a catering service in Rome. The risk analysis assessment was performed by means of a checklist that collected systematically all data about the environment, the operators, the food and the catering process. The results of the microbiological analysis carried out in the CCP's showed that the general conditions of the catering service were not satisfactory, but also indicated the validity of the checklist used. This method showed a high predictive value and can be useful to improve the application of the HACCP system.

Cold chain status at immunisation centres in Ethiopia

BACKGROUND

Child immunisation is among the most cost-effective ways of preventing premature child deaths, and the potency of vaccines, crucial for vaccine efficacy, is dependent on effective management of the cold chain at all levels of vaccine handling.

OBJECTIVE

To assess the status of the cold chain at peripheral vaccine stores in Ethiopia.

DESIGN

Institution based cross-sectional survey in two rural and one urban administrative areas were included in the study. Sixty seven health institutions providing static vaccination services were included in the study but cold chain system was assessed fully in only sixty four. Data were collected by interviewing health workers and by directly observing the cold chain equipment and records using structured forms.

RESULTS

Conditions of the cold chain system were described based on 64 of the 67 centres visited, three were excluded because of non-functioning cold chain. Complete temperature record was observed in 37 (57.8%) of the centres. Thermometer was not available in four (6.3%) and thermometer reading was found to be outside the optimal range in another seven (10.9%) centres. Vaccine storage in the refrigerator was not proper in 47 (73.4%) centres. Majority of the centres had neither trained personnel nor budget for maintenance of the cold chain.

CONCLUSION

There is a real danger of vaccines losing their potency at these centres even if they were potent on arrival. Relevant training for those handling the cold chain, improving the maintenance conditions of refrigerators and introduction of cold chain monitoring devises are recommended.

Storage of breast milk: effect of temperature and storage duration on microbial growth

OBJECTIVE

To study the effect of storage duration at varying temperature ranges, the pattern of microbial isolates and the quantity of colony-forming units (CFU) on expressed breast milk.

DESIGN

Cross sectional study.

SETTING

Bacteriology laboratory, University of Zimbabwe in Parirenyatwa Hospital, Harare.

MAIN OUTCOME MEASURES

The temperature, storage duration and types of micro-organisms in freshly expressed breast milk.

RESULTS

Freshly expressed human breast milk contained microbial non-pathogens of skin flora. There was no growth of organisms in stored breast milk after four hours, eight hours, 24 hours and 72 hours storage duration at temperature ranges 0 to 4 degrees C (freezing temperature), 4 to 10 degrees C (refrigerator temperature), 15 to 27 degrees C (room temperature) and 30 to 38 degrees C (high temperature) respectively. Growth was detected after the storage durations and organisms isolated were both pathogens and non-pathogens with low counts. Average colony counts was (CFU < 200).

CONCLUSION

The study revealed that storage duration for expressed breast milk should not exceed 24 hours in refrigerator temperature (4 to 10 degrees C), eight hours at room temperature (15 to 27 degrees C) and four hours at high temperature (30 to 38 degrees C). Although freezing temperature (0 to 4 degrees C) seemed safest for breast milk storage, short-term storage in a freezer is not recommended due to likely the hazards of the thawing process.

Questions & answers from the JCAHO. When to log refrigerator temps

The Joint Commission has standards for appropriate storage of medication, as well as food and nutritional products. Learn what the standards say about your staff watching the "fridge."

[Condensation water drainage of cooling systems in cold storage rooms--a problem of hygiene]

There has been accumulation of water and of dusty dirt in many condensation water containers of cooling systems in cold-storage rooms. Random but thorough microbiological testing of these accumulations in hospital kitchens proved the presence of possible agents that promote spoiling of food, pathogens of infections and food poisons. This is due to technical and hygienic flaws particularly as far as maintenance and condensation drainage are concerned. There are no regulations for technical and hygienic standards in cold-storage rooms e.g. according to DIN, ISO or VDI. However, such regulations are essential. Cooling systems should be included in the DIN 1986 prescriptions (air-conditioned systems) or receive their own regulations. On account of the present findings air-condition systems require specification and extension of the existing standards esp. in the area of condensation drainage and regular disinfectant cleaning.

Vaccine storage in the community: a study in central Italy

Maintaining the vaccine cold chain is an essential part of a successful immunization programme, but in developed countries faulty procedures may occur more commonly than is generally believed. A survey was conducted in a health district in central Italy to assess the methods of vaccine transportation and storage. Of 52 primary vaccination offices inspected, 39 (76.5%) had a refrigerator for vaccine storage but only 17 (33.3%) kept records of received and stored doses. None of the seven main offices selected for monitoring had a maximum and minimum thermometer and none monitored the internal temperature of the refrigerator. Moreover, other faulty procedures, such as the storage of food and laboratory specimens in vaccine refrigerators and the storage of vaccines on refrigerator door shelves, indicated that the knowledge and practice of vaccine storage and handling were often inadequate.

[Effect of various methods of tissue storage on split-skin viability at 4 degrees C]

OBJECTIVE

To study various tissues and organs storage solutions (liver, kidney and corneal) at 4 degrees C for the storage of skin and the viability of skins stored in these solutions at correspondent condition.

METHOD

Five experiment groups investigated for storing porcine split-skin at 4 degrees C were MEM, UW, MEM plus CS, UW-R and MEM-R. A new assay, WST-1, was applied to evaluate skin viability at 1, 3, 5, 7, 10 and 14 day during storage respectively.

RESULT

Skin viability can all be protected by these three solutions. The effect of UW solution was superior to MEM. UW-R and MEM-R were superior to MEM and UW.

CONCLUSION

The method of UW-R which replaces medium routinely may be an optimal method of storing skin at 4 degrees C.

Vaccine storage in pharmacies on the Central Coast of New South Wales

Pharmacies on the Central Coast of NSW were surveyed to assess the ability of refrigerators used for vaccine storage to maintain the recommended temperature range (2 to 8 degrees C). Refrigerators used for vaccine storage were monitored over a 3-day period using a temperature data logger. Fifty-nine (59) retail pharmacies were identified. The response rate was 90% (53/59) and 52 refrigerators were monitored successfully. Only 10 (19%) of the refrigerators maintained temperatures wholly within the recommended range for the 3-day monitoring period. The remaining refrigerators were considered in three groups--refrigerators keeping temperatures in the range 0.1 to 11.9 degrees C, below 0 degree C and above 8 degrees C for most of the time. There were 15 (29%), 12 (23%) and 15 (29%) refrigerators in these groups respectively keeping temperatures in the recommended range for 91%, 19% and 30% of the time. Of the refrigerators achieving temperatures below 0 degree C, none went below -5 degrees C and on average they kept temperatures less than 0 degree C for 49% of the time. This survey highlights the need for vigilance in vaccine storage for immunisation programs to be successful. Of the vaccines affected by freezing, hepatitis B vaccine was identified as being most at risk.