Evaluation of Temperature Monitoring System of Cold Chain at all Urban Health Centres (UHCs) of Ahmedabad Municipal Corporation (AMC) area.

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1 Original Article Healthline Jurnal Vlume 6 Issue 1 (January - June 2015) Evaluatin f Mnitring System f Cld Chain at all Urban Health Centres (UHCs) f Ahmedabad Municipal Crpratin (AMC) area. 1 2 Kapil J. Gvani, Jay K. Sheth Assistant Prfessr, Dept. f Cmmunity Medicine, GMERS Medical Cllege, Valsad, Gujarat, India. Dept. f Cmmunity Medicine, Smt. NHL Municipal Medical Cllege, Ahmedabad, Gujarat, India. Crrespnding Authr : Kapil J. Gvani, E mail: kapilgvani@gmail.cm 1 2 Assistant Prfessr, Abstract : Intrductin : mnitring system is an imprtant element f cld chain. Objectives : 1) T evaluate the temperature mnitring system f cld chain at UHC level.2) T take necessary crrective measures whenever required and give relevant advices t handlers fr imprving the system. Methd : A crss sectinal study was cnducted at all the 56 UHCs f AMC area during May 2012 t January Pretested check list was used having details f varius cld chain elements. Results & Discussin : Significant difference was fund regarding the placement f alchl & dial thermmeter in ILR & DF respectively (P: 0.028). Dcumentatin f temperature in temperature lgbk twice daily n regular basis was satisfactry. Pr dcumentatin was nted fr pwer failure (12.5%) and fr defrsting status (41%) in recrd bk. ILR (Ice Lined Refrigeratr) breakdwn was nted significantly in temperature lgbk (P: 0.004). Cnclusin : lgbk was regularly updated still there was scpe fr imprvement regarding dcumentatin f pwer failure and defrsting status. Key wrds : recrd,cld chain, UHC Intrductin : Cld chain is a system f string and transprting vaccine at the recmmended temperature range frm the pint f manufacture t [1-3] pint f use. Cld Chain and vaccine management are the left and right hands f immunizatin [4] prgramme. mnitring system was very imprtant cmpnent t avid cld chain failure. Deep Freeze (DF) and Ice Lined Refrigeratr (ILR) are t electrical equipment available at UHC level. A break in the cld chain is indicated if temperature rises abve +8 C r falls belw +2 C in the ILR; and abve - [5, 6] 15 C in the Deep Freezer. The ILR and Deep freezers each shuld have separate thermmeter and temperature recrd bk and temperature must be [3,7] recrded twice daily (mrning and evening). After recrding the temperature, cld chain handlers shuld sign n the temperature recrd bk. Every week Medical Officer (MO) in-charge shuld recrd [8] the temperature and sign n the recrd bk. such recrds shuld be checked during supervisry visits. The thermmeter shuld be kept in between the freeze sensitive vaccine inside the basket f the ILR. [2,9] [1] There are mainly three types f thermmeter. :: 41 :: Dial thermmeter: It has dial with mving needle t shw the temperature f vaccine within the range f -50 C t +50 C.(2) Alchl Stem thermmeter: It is much sensitive and accurate than dial [5, 10] thermmeters. They can recrd temperatures frm -50 C t +50 C and can be used fr ILRs and deep freezers. As it is very sensitive, it shuld nt be taken ut frm the ILR and reading must be nted immediately.(3) Electrnic / Digital thermmeter: It is als knwn as cntrl panel. Every vaccinatin is nt immunizatin s ptency f all vaccines needs t be well maintained. One f imprtant cmpnent f cld chain is maintaining each vaccine in recmmended temperature fr vaccine ptency. Dealing with larger number f vaccine stcks in majr cities, is als increases the chance f cld chain failure. The Ahmedabad Municipal Crpratin (AMC) is an urban area with many challenges, as far as maintenance f cld chain is cncerned. Thus, lking in details f cld chain system in an urban area is very much required. S study was cnducted at all UHCs f AMC with fllwing bjectives.

2 Gvani & Sheth Evaluatin f Mnitring... Objectives : tested, was used fr data cllectin purpse at all UHCs. The check list cntains details f varius 1) T evaluate the temperature mnitring cmpnents f cld chain. Amng them ne f the system f cld chain at UHC level. imprtant cmpnents is temperature mnitring 2) T take necessary crrective measures system. Which cntents (1) Evaluatin f whenever required and give relevant advices t temperature lgbk recrds (2) Availability, handlers fr imprving the system. placement and functinal status different types f Methd : thermmeter. At each UHC this check list was filled and crrective measures were taken wherever Ahmedabad Crpratin is divided in 6 znes necessary. Data entry was carried ut and data and has ttal 57 wards with a city ppulatin f analysis was dne by using apprpriate statistical [11] 5,570,585. Zne wise distributin f fifty seven sftware and applying suitable statistical tests. UHCs shws that West Zne (WZ), New west Zne (Nwz), East Zne (Ez) and Nrth Zne (Nz) have 10 Results : UHCs each. While Central Zne (Cz) is having 09 UHCs Amng all UHCs, 54 DFs and 53 ILRs were and Suth Zne (Sz) is having 08 UHCs.The present fund in wrking cnditin. digital (electrnic) crss sectinal study was cnducted at all 56 UHCs f AMC area during May 2012 t January 2013.As far as the cld chain system f UHC is cncern, there are fifty six UHCs, because tw UHCs f East znes (Rajpur and Rakhiyal) are wrking as a single unit fr immunizatin cverage and there is single set f all cld chain equipments fr bth UHCs. In AMC area respnsibility f cld chain and vaccine management at all UHCs is under Registrar f Birth & Death department (RBD department). Due permissin was taken frm RBD department, Health sectr, AMC. Institutinal Review Bard (IRB) f Smt. N.H.L. Municipal Medical Cllege, Ahmedabad apprved the study and gave ethical clearance. Fully structured checklist, which was specially designed and prethermmeter was present in many f electrical equipments but was nt in wrking cnditin, in all f them. Majrity f DF & ILR had internal thermmeter. Significant findings were nted regarding availability f alchl thermmeter in ILR and dial thermmeter in DF (Table-1). As cmpare t digital (electrnic) thermmeter, temperature f internal thermmeter was nted in temperature recrd bk at majrity f UHCs. Cmplete temperature recrd f last 1 year was available nly at 21 (37.5%) f the UHCs. There were significant breakdwns in ILR as cmpare t DF. At 4 UHCs a ttal f 6 DF breakdwns were reprted (At 1 UHC 3times DF breakdwn in 1 year). Fr ILR, a ttal f 20 breakdwns were reprted at 17 UHCs (With 2 & 3 breakdwn at ne UHC each) (Table-1). Table 1 : Status f temperature mnitring system f Electrical equipments at UHC level. Sr. Pints t be bserved Internally DF (N=54) ILR (N=53) Chi- P N. fr DF (N=54) and ILR (N=53) Equipment square value Yes N Yes N value 1.a Digital Thermmeter (Electrnic) present b Digital Display in Wrking cnditin c Digital Display in visible cnditin a Separate internal thermmeter present b Alchl thermmeter present c Dial thermmeter present d Functinal thermmeter prperly placed a Alchl thermmeter temp. in recrd bk b Dial thermmeter temp. in recrd bk c Digital thermmeter temp. in recrd bk d Cmplete data recrds f temperature in temp bks f last 1 year 3.e Equipments breakdwn nted in temp. bks at UHCs (last 1 year data) :: 42 ::

3 All the UHC had temperature recrd bk/lgbk. Majrity (83.9%) had placed it nearer t DF/ILR. Mnitring f temperature f electrical cld chain equipments n daily basis was satisfactry (92.9%) but pr dcumentatin f pwer failure/cut (12.5%) and defrsting status (41.1%) was bserved (Table-2). Crss check by MO f UHC was dne n regular basis. As per health staffs, external supervisin by AMC was satisfactry with a Healthline Jurnal Vlume 6 Issue 1 (January - June 2015) mean 3.1 supervisry visit per year. Hwever dcumentatin in temperature recrd bk was nt supprting this fact with an average 1.2 supervisry signature per year. Technical / mechanical services f DF/ILR were n call and nt regularly basis. Nt cnsidering the rutine inspectin and maintenance visit by the technician, and nly cnsidering the 26 breakdwns, signature f technician was fund at nly 2 UHCs (Table-2). Table2:Evaluatin f recrd bk at UHC level. Sr. Details f temperature recrd bk Yes Percentage N. (N=56 UHCs) (N.) (%) 1 recrd bk available recrd bk put nearer t DF / ILR recrd bk up t date till nw Dcumentatin n pwer failure/cut dne in temperature bk (last 1 year data/recrd) 5 Dcumentatin n defrsting status dne in temperature bk (last 3 mnths data/recrd) 6 Crss check by MO (see signature). (last mnth data) Recrds f external checking by AMC available in temperature bk (last 1 year data) Signature f technician dne in temperature bk (last 1 year data/recrd) detail f different types f thermmeter and recrd data fr ILR and DF accrding t their availability was mentined in Table-3 & Table-4. Majrity f internal Table3:Cmparisn amng temperature related data frm different surces fr Ice Lined Refrigeratr (ILR) equipment. Sr. Seen n Internal In N. details fr Digital thermmeter ILR thermmeter (Alchl/Dial) recrd bk f ILR (N=27) (N=51) (N=49) 1-2.C C C C t8.C thermmeter findings shws nrmal temperature range fr bth DF & ILR (Table-5). Summary measures f temperature details f cld chain equipments were as per Table-6. Table4:Cmparisn amng temperature related data frm different surces fr Deep Freeze (DF) equipment. Sr. Seen n Internal In N. details fr DF Digital thermmeter thermmeter (Alchl/Dial) recrd bk f DF (N=50) (N=29) (N=49) 1-30t-26.C t-25.C t-11.C t-06.C t0.C :: 43 ::

4 Gvani & Sheth Evaluatin f Mnitring... Table5:Cmparisn f internal thermmeter (Alchl / Dial) temperature range between DF & ILR equipments. Sr. N. Internal DF ILR Chi- P value thermmeter (N=49) (T= -15 (N=51) (T= 02 square value details fr t -25 C) t 08 C) DF and ILR 1 Abve Nrmal Nrmal Belw Nrmal Table 6 : Summary measures f temperature details f cld chain equipments. Sr. Details f cld chain Mean SD Min. Max. Median N. equipment 1 DetailsfDF 1.a Display b Internal Thermmeter c Recrd bk DetailsfILR 2.a Display b Internal Thermmeter c Recrd bk Discussin : As discussed, majrity f DF & ILR had separate internal thermmeters. As alchl thermmeter is mre sensitive, it is preferred ver dial thermmeter [3] fr ILR. The present study shws the significant findings regarding availability f alchl thermmeter in ILR and dial thermmeter in DF (Table-1). The uter digital temperature indicatr shuld nt be recrded but was used at 8/54 & 6/53 UHCs fr ILR & DF respectively. mnitring system is ne f the imprtant systems f cld chain maintenance. recrd bk is key cmpnent fr mnitring the temperature [1,2] regulatin. At all UHCs dcumentatin f temperature twice daily n regular basis was satisfactry. But dcumentatin recrd f pwer failure, defrsting f DF, Technical / mechanical service f DF/ILR etc. was prly maintained. :: 44 :: recrd bk was satisfactrily crss checked by Medical Officers (89.3%) but external crss checking by AMC (75%) need sme imprvement. This may equally be attributed t laxity n part f external supervisrs wh fail t sign in spite f supervising the system. In the study, data fr the temperature mnitring system were cllected frm different surces, e.g. Digital thermmeter temperature, internal thermmeter temperature (Alchl/Dial) and frm recrd bk data. The cmparisn was dne amng temperature related data frm different surces as shwn in Table- 3 and Table-4 fr ILR and DF respectively. Majrity f the temperature were within nrmal range fr the equipment. The recrded temperature was almst similar t the internal temperature measured. As frm the abve tables (Table-3 & 4) temperature range f internal thermmeter f DF and ILR was cmpared with each ther which shwed that there was significant difference between DF and ILR fr temperature range abve nrmal level (Table-5). But majrity f internal thermmeter findings shws nrmal temperature range fr bth DF & ILR. Overall mean temperature f recrd bk, internal thermmeter (Alchl/Dial) and f digital thermmeter was similar (Table-6). Cnclusin and Recmmendatins : Althugh nt unifrm, significantly higher number f alchl thermmeter is used in ILR whereas dial thermmeter in DF. At all UHCs dcumentatin f temperature twice daily n regular basis was satisfactry but ther dcumentatin e.g. defrsting status, pwer failure / cut, technical / mechanical services etc. was pr. Majrity f internal thermmeter findings shws nrmal temperature range fr bth DF & ILR. Regular cld chain training fr handlers at UHC level shuld be rganized by the health authrity f the AMC area. References : st 1. Park's text bk f Preventive and Scial medicine, K. PARK, 21 editin, M/s Banarsidas Bhant,1167- prem nagar, Jabalpur (M.P.), India. 2. Handbk fr Vaccine & Cld Chain Handlers 2010, Department f Health & Family Welfare Ministry f Health and Family Welfare Gvernment f India.

5 Healthline Jurnal Vlume 6 Issue 1 (January - June 2015) 3. Ministry f Health & Family Welfare, Gvernment f India. Immunizatin Handbk fr Medical Officers. New Delhi: Dept. Health & Family Welfare, Gvt. f India, Immunizatin In Practice: A Practical Resurce Guide fr Health Wrkers, Geneva, Wrld Health Organizatin, 2004, (WHO/IVB/04.06), 5. India Natinal Universal Immunizatin Prgramme Review, New Delhi, United natins children's fund- Wrld Health Organizatin, 2004, 6. Natinal Family Health Survey (NFHS-3), : India, Mumbai, Internatinal Institute f Ppulatin Sciences and Macr Internatinal, Immunizatin Essentials: A Practical Field Guide, Washingtn, D.C., United States Agency fr Internatinal Develpment, 2003, Immunizatin Handbk fr Health Wrkers, New Delhi, Gvernment f India, Outbreaks Investigatin and Cntrl, New Delhi, Natinal Institute f Cmmunicable Diseases, Gvernment f India, 1998, ( DGHS/98) 9. Natinal Immunizatin Prgramme: Cnduct Disease Surveillance, New Delhi, Gvernment f India, Reprductive and Child Health Prgramme, Immunizatin Strengthening Prject: Training Mdule fr Mid-level Managers, New Delhi, Gvernment f India, (accessed n December 30, 2011) :: 45 ::

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Subject description processes Subject representatin 6.1.2. Subject descriptin prcesses Overview Fur majr prcesses r areas f practice fr representing subjects are classificatin, subject catalging, indexing, and abstracting. The prcesses