Vaccine Transportation Series: What Limitations Affect Cold Chain Logistics?

Millions of children die every year of preventable diseases because of the inefficient or inexistent refrigeration needed to get them vaccines that already exists.

If after reading the first piece of this series you still find yourself wondering about the relevance this issue might have, think about this: Imagine a scenario where there’s an outbreak of a virus (like the Ebola virus disease) for which there’s no cure or vaccine yet.

With the current outbreak of the Ebola virus, the more severely affected regions are developing countries in West Africa. According to the WHO, “The most severely affected countries, Guinea, Sierra Leone and Liberia have very weak health systems, lacking human and infrastructural resources, having only emerged from long periods of conflict and instability”.

Even though currently there are no licensed Ebola vaccines, there are 2 potential candidates undergoing evaluation according to the WHO. Imagine what might happen if the temperature during the transportation and/or storing of the experimental vaccines to treat the virus affected the results of the trials? Or more realistically, what if a cure is found and the temperature of the vaccine needs to be kept among a specific range? How would developing countries with weak health systems overcome their difficulties to control that the cold chain of the vaccines remains unbroken? What if the vaccines fall out of their recommended temperature range and are still administered to infected patients? According to a recent article from Forbes titled “The one simple but crucial technology overlooked in the fight against Ebola,” the author stated, “Temperature control will matter for both vaccines and treatments, since many of the kinds of drugs being studied for Ebola are delicate biological compounds, vulnerable to irreversible chemical changes if allowed to get too warm or if frozen”.

Currently, the Ebola epidemic has spread in Liberia to the point where “No free beds for Ebola treatment exist anywhere in the country”. Healthcare workers are highly exposed to being infected and many have died. As of right now the country already faces the need for beds, supplies, and staff. What if on top of that we added the need for successful cold chain operations and refrigeration to treat the disease? The ultimate challenge will be getting refrigeration systems and power sources to maintain the cold chain unbroken until vaccines reach the patients.

This piece will explore past events where the mishandling or bad practices during the transportation, storage or monitoring of heat-sensitive vaccines have had tragic consequences in developing countries

The Case of Polio in Pakistan

As of October 3, 2014, ABC News reported 194 cases of Pakistani patients affected by polio, which is very close to their national record number of 199 in 2001 (source). Even though Polio can be easily prevented with a vaccine, Pakistanis face many challenges to prevent the disease. Besides geographical and economic barriers, many affected areas can’t be accessed by anti-polio campaigns because of the threats of Taliban militants.

The family of a 2-year-old boy from a small village in North Waziristan shared their story with NBC News; since Taliban militants prevented the access of health workers to their village, the boy’s father and uncle chose to put themselves at great risk by smuggling the vaccine from the largest nearby town into their village in order to keep the children in their family healthy. The 16-year-old uncle said, “I was afraid but wanted to vaccinate our children at any cost”.  Even though they managed to get the 2-year-old boy a few doses of the vaccine, he contracted Polio. The potency of the Polio vaccine can be weakened if the cold chain is broken, and it was difficult for the uncle to assess whether he’d managed to keep the vaccines at a constant temperature while he transported them. In 2012, 58 Pakistani children became infected with Polio despite having properly received all doses of the vaccine.

Faulty refrigeration in Honk Kong

On September 25, 2014 a nurse noticed a faulty refrigerator at the Tuen Mun Hospital. Between September 23 and September 25, 2014 over 40 children had received BCG and hepatitis B vaccines that were being kept at a temperature of 19 degrees Celsius, due to the faulty refrigerator (source). The hospital expressed its apologies and assured the vaccines wouldn’t affect or harm the recipients, however, the event is still under investigation. On a press release the hospital committed to investigate the cause of the issue to prevent it from happening again.

Thread of epidemic in flooded Kashmir

The Indian region of Kashmir copes with a recent flooding that killed hundreds of people and affected hundreds of villages, leaving hundreds of thousands of people living in temporary shelters. The flooding (caused by days of rain and the swelling of two rivers) has raised many concerns from health-care practitioners. “There are pretty high chances of waterborne diseases and diseases due to overcrowding," said the specialist Dr. Javaid Naqishbandi.

The risk of water-borne diseases increase with a lack of access to clean water (or chlorine tablets), dead animals floating around the streets, and the unavailability of vaccines that protect against water-borne diseases at the medical camps where people are being treated.

Shahid Bhat is a volunteer who visited several private hospitals and medical camps looking for vaccines in response to the rising cases of gastro-enterological problems; he said, “All the hospitals said they did not have the vaccines due to lack of electricity. A vaccine needs to be refrigerated or it will get destroyed”.

After reviewing these events, we can better understand how difficult it can be to maintain the effectiveness of vaccines when challenges arise. Whether it’s the lack of electricity that prevents the access to heat-sensitive vaccines, an inaccurate monitoring of temperature during the storage of vaccines, or when the cold chain is broken during the transportation of vaccines, developing countries face many adversities to maintain vaccines between their recommended range of 2 to 8 degrees Celsius.

When many outside factors, including efficient access to electricity, contribute to the struggle of maintaining the cold chain, the monitoring at every link of the process becomes critical and fundamental to achieving the desired results from using the vaccines.