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.
Large areas of many developing countries have no grid electricity. This is a serious challenge that threatens the continuity of the vaccine cold chain. The main alternatives to electrically powered refrigerators available for many years--kerosene- and gas-driven refrigerators--are plagued by problems with gas supply interruptions, low efficiency, poor temperature control, and frequent maintenance needs. There are currently no kerosene- or gas-driven refrigerators that qualify under the minimum standards established by the World Health Organization (WHO) Performance, Quality, and Safety (PQS) system. Solar refrigeration was a promising development in the early 1980s, providing an alternative to absorption technology to meet cold chain needs in remote areas. Devices generally had strong laboratory performance data; however, experience in the field over the years has been mixed. Traditional solar refrigerators relied on relatively expensive battery systems, which have demonstrated short lives compared to the refrigerator. There are now alternatives to the battery-based systems and a clear understanding that solar refrigerator systems need to be designed, installed, and maintained by technicians with the necessary knowledge and training. Thus, the technology is now poised to be the refrigeration method of choice for the cold chain in areas with no electricity or extremely unreliable electricity (less than 4h per average day) and sufficient sunlight. This paper highlights some lessons learned with solar-powered refrigeration, and discusses some critical factors for successful introduction of solar units into immunization programs in the future including: •Sustainable financing mechanisms and incentives for health workers and technicians are in place to support long-term maintenance, repair, and replacement parts. •System design is carried out by qualified solar refrigerator professionals taking into account the conditions at installation sites. •Installation and repair are conducted by well-trained technicians. •Temperature performance is continuously monitored and protocols are in place to act on data that indicate problems.
Evidence regarding the effectiveness of continuing medical education (CME) is reviewed in terms of three possible end- products : physician competence, physician performance, and patient health status. Results of this review are presented in the context of recent increases in mandatory CME policies and the corresponding cost of such policies to the nation. The number of CME activities is evidently on the increase. Yet, according to conventional wisdom, CME is not effective. To the contrary, about half of the 47 evaluation studies published since 1960 reported demonstrable improvement in at least one of the three end-products following CME. However, methodological shortcomings in many of these studies make it impossible to conclude that the improvements were caused by the CME. The authors discuss the need for more research surrounding the subject of CME and its effectiveness.
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