Illustration: cold chain (unicef.org)The Covid-19 pandemic has hit the world for more than a year and a half, including Indonesia. One of the government's efforts to deal with the Covid-19 Pandemic is by implementing the health protocol that we already know as the 5 M's. Not enough with the 5 M health protocol, the government also implements prevention efforts, which is by vaccination.
To succeed in the implementation of Covid-19 vaccination, cooperation from all parties is needed. Government Pharmaceutical Installations and immunization program administrators, both at the Provincial and District/City Health Offices, have a very important role in managing the Covid-19 vaccine. Various efforts need to be made to maintain the availability and quality of the distributed Covid-19 vaccine so that the vaccine can be optimally utilized in the vaccination provider facilities.
North Kalimantan Province, which is the fostered area of the Directorate of Public Drug Management and Health Supplies, is one of the provinces that actively organizes Covid-19 vaccination. In organizing the Covid-19 vaccination, there are challenges faced by North Kalimantan Province. The infrastructure and geographical location of North Kalimantan Province through mountains, rivers, sea and air resulted in the need for different transportation fleets. This raises the need for Covid-19 vaccine security that is in accordance with different modes of transportation to maintain the quality of the Covid-19 vaccine distributed. In this regard, increasing the capacity of Covid-19 vaccine managers in terms of vaccine storage and security during distribution is needed.
On June 24, 2021, the Directorate of Public Drug Governance and Health Supplies conducted regional guidance activities which were carried out online. The activity aims to increase the capacity of covid-19 vaccine managers in North Kalimantan Province, especially in terms of vaccine storage and security during distribution. Participants came from the North Kalimantan Provincial Health Office, Bulungan District Health Office, Tarakan City Health Office, Nunukan District Health Office, Malinau District Health Office, Tana Tidung Health Office, Directorate General of Disease Control and Prevention, and Directorate General of Pharmaceuticals and Medical Devices. The resource person at the activity was Mr. Sukma Anugrah from PT Bio Farma, presenting Cold Chain Management material (Covid-19 Vaccine).
Cold Chain Management is a system used to store and distribute vaccines and other biological products in good condition. Cold chain is a series of activities from the beginning of vaccine manufacture, until the vaccine is used and is designed to keep the vaccine at the temperature recommended by the world health organization (WHO). Some of the reasons the cold chain is important are that vaccines can be damaged by excessive exposure to heat, cold (freezing) temperatures and light, and public trust in vaccines.
Cold Chain Management provides an understanding of the importance of equipment, facilities, and monitoring in the distribution and storage of vaccines, even up to the receipt of vaccines at their destination. Regarding equipment needs, it is divided into 3 levels. The primary level (national) requires cold/freezer rooms, chiller/freezers, cold boxes, and vehicles with refrigeration used as a means of transportation. At the Intermediate level (provincial), it can be said that it is still the same as the primary level because at this provincial level, it is necessary to store and distribute to districts / cities whose distance and time are not uniform. Then at the peripheral level (Puskesmas), the equipment used is simply a chiller, cold box, vaccine carrier.
As a form of monitoring of vaccines, some of the equipment used during storage and distribution are Jumo (to monitor temperature for 24 hours), Vaccine Vial Monitor (VVM) as an indicator of exposure to hot temperatures in vials, Freeze Alert for vaccines that are sensitive to freezing temperatures, and so on. In the receiving process, all conditions of vaccines received must be checked and recorded properly, at least on the product name, product quantity, physical condition, batch number, expiration date, condition of the temperature monitor, and condition of the VVM. If the condition of the temperature monitoring device or VVM shows any deviation, it can be reported to the sender of the accompanying cold chain product. When the vaccine is stored, temperature monitoring needs to be done at least twice a day. The unstable condition of electricity lines in the North Kalimantan Province area means that vaccine storage must be secured. Generators must be prepared to maintain cold temperatures in the event of a power outage.
Technically, vaccine storage is divided into several classes. For example, Pfizer's covid-19 vaccine is stable at -60ºC to -80ºC and Moderna's -15ºC to -25ºC is categorized in class A, BCG, measles and MR vaccines are stable at 2ºC to 8ºC but in emergencies can be stored at -15ºC temporarily. Meanwhile, the covid-19 vaccine (Sinovac, Biopharma, Sinopharm, Novavax, AstraZeneca) is stable at 2ºC to 8ºC and is categorized as class C. For class A vaccines, storage is closer to the cold source, but for class C it is away from the cold source. The correct way to store vaccines is not tightly packed and given circulation, separation and marking in each batch, then freeze alert is brought closer to the cold source at the vaccine storage location at a temperature of 2ºC to 8ºC.
With the natural conditions of Kalimantan Province, a more complex distribution method is needed. For example, for shipping it is necessary to use containers that are validated and meet shipping standards. What needs to be done during validation is to prepare the coolbox / vaccine carrier, then insert the coolpack / coldpack / dry ice according to the vaccine product to be validated (class a / b / c) with the amount according to the size of the coolbox. After the vaccine product is placed in the coolbox/vaccine carrier, the calibrated thermometer sensor is placed in the farthest and/or closest position from the cold source. The coolbox is then closed and shipment is made to the destination that requires the longest time. Temperature monitoring is carried out during shipment at intervals such as every 10 minutes. When monitoring the temperature, the coolbox lid is opened and the temperature indicated by the thermometer is recorded. Validation is considered successful if the temperature during delivery meets the requirements (delivery temperature class a/b/c) after temperature evaluation. If it does not match, it can be corrected by exchanging or increasing the number of coolers and replacing the coolbox. Furthermore, the final results of the validation can be used as standard vaccine packing procedures.
Another thing that is no less important when shipping is that it is advisable to use refrigerated vehicles so that the vaccine can be received in good condition. In addition, there must also be prior communication to the vaccine recipient in the area. Furthermore, the duration of delivery time is adjusted to the validation results. If the delivery duration is longer, there must be a transit place for the cooling media replacement process.
Although vaccine management has implemented Cold Chain Management, there are problems that can interfere with the success of the system. Limited cold chain facilities and equipment and unstable electricity supply can affect vaccine storage temperatures. Based on this, it is necessary to increase support from the local and central government so that this system can run well. [Breni]
Activity material can be downloaded below.
