title: Reducing the loss of vaccines from accidental freezing in the cold chain: the experience of continuous temperature monitoring in Tunisia.
abstract: Accidental freezing of vaccines is a growing threat and a real risk for national immunization programs when the potency of many vaccines can be compromised if these are exposed to sub-zero temperatures in the cold chain. In Tunisia, this issue is compounded by using sub-standard domestic cold chain equipment instead of equipping the program with medical refrigerators designed specifically for storing vaccines and temperature sensitive pharmaceuticals. Against this backdrop, this paper presents the findings of a demonstration project conducted in Tunisia in 2012 that tested the impact of introducing several freeze prevention solutions to mitigate the risk of accidental freezing of vaccines. The main finding is that, despite the continued use of underperforming domestic refrigerators, continuous temperature monitoring using new technologies combined with other technological interventions significantly reduced the prevalence of accidental exposure to freezing temperatures. These improvements were noticed for cold chain storage at regional, district and health center levels, and during the transport legs that were part of the demonstration conducted in the regions of Kasserine in the South-Eastern part of Tunisia. Subsequent to introducing these freeze prevention solutions, the incidence of freeze alarms was reduced and the percent of time the temperatures dropped below the 2 °C recommended threshold. The incidence of freeze alarms at health center level was reduced by 40%. Lastly, the solutions implemented reduced risk of freezing during transport from 13.8% to 1.7%. Although the solution implemented is not optimal in the longer term because domestic refrigerators are used extensively in district stores and health centers, the risk of accidental freezing is significantly reduced by introducing the practice of continuous temperature monitoring as a standard. The management of the cold chain equipment was strengthened as a result which helps protect the potency of vaccines to the areas of most difficult access.
authors.affiliation: PATH, Ferney-Voltaire, France. Electronic address: john.lloyd1945@gmail.com.
authors.forename: John
authors.initials: J
authors.lastname: Lloyd
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Patrick
authors.initials: P
authors.lastname: Lydon
authors.affiliation: World Health Organization, Tunis, Tunisia.
authors.forename: Ramzi
authors.initials: R
authors.lastname: Ouhichi
authors.affiliation: World Health Organization, Geneva, Switzerland.
authors.forename: Michel
authors.initials: M
authors.lastname: Zaffran
mesh_terms: D004355:Drug Stability; D004356:Drug Storage; D005615:Freezing / Q000009:adverse effects*; D012034:Refrigeration; D013696:Temperature; D014416:Tunisia; D014612:Vaccines
chemical_list: D014612:Vaccines
keywords: Cold chain; Domestic refrigerator; Freezing vaccine; Temperature monitoring