REPORT Technical review and assessment of existing vaccine storage facilities in

The Republic of Peru 1st to 16th August, 2003

by

Søren Spanner, Technical Officer, UNICEF Supply Division, Copenhagen

Ministerio de Salud

2

ACRONYMS CFC Chloride Fluorine Carbon CLM Commodities and Logistic Management DISA National Health Institute and 11 Health Departments by

their acronym in Spanish EPI Expanded Programmer on Immunization ILR Ice-lined Refrigerator MINSA Peru’s Ministry of Health (MINSA by its acronym in Spanish) PAHO Pan American Health Organization R12 Refrigerant 12 R134a Refrigerant 134a (CFC free) UNICEF United Nations Children's Fund WHO World Health Organization WIC Walk in Cold Room WIF Walk in Freezer Room.

3

LIST OF CONTENTS:

PAGE ACRONYMS...................................................................................................................... 2 People met:.........................................................................Error! Bookmark not defined. Executive summary............................................................................................................. 4 Mission objectives (as received)......................................................................................... 5

Debriefing at MINSA on 14.08.03: ................................................................................ 5 MINSA: WIC/WIF ............................................................................................................. 6 Recommended Action Points for National Cold Store ....................................................... 7 Draft TOR for Temperature Monitoring and Inventory Consultant. .................................. 8 Visits to Health Centers and vaccine stores in Lima, Cusco and Apurimac provinces. ..... 8

Lima Province:................................................................................................................ 8 Cusco Province: ................................................................................................................ 10 Apurímac Province: .......................................................................................................... 13 Summary of recommendations: ........................................................................................ 15 Programme for the Visit of ................................................Error! Bookmark not defined. Acknowledgements The writer would like to express a very warm and sincere thank you to the Government of Peru and especially the Minister of Health, Dr. Alvaro Vidal for giving the opportunity to debrief and work closely with the officers concerned. I would also like to thank the local UNICEF office for their assistance, special thanks goes to Mario and Patricia for their commitment. A special thank you goes to Mr. Victor Gomez, PAHO Consultant, who joined me, unfortunately in Lima only.

4

Executive summary The National Cold Store is extremely well organized and correct storage practices are followed. It is the best National Store I have ever seen!. The vaccine storage space is limited , other than EPI vaccines are being stored and additional storage space is required, two combined cold/freezer rooms, like the new room donated by JICA, 50m3 each. Both the vaccine inventory and the temperature recording is manual, a computerized system for both would improve the quality of both. The two old cold/freezer rooms are about 20 years of age and of the CFC type, however they are very well maintained and running well. The freezer room is currently being upgraded to CFC-free, this is also recommended be done for the cold room. The situation in the provinces is different, vaccines and equipment is well looked after, however because of lack of training, high turn over of staff and use of “domestic type of equipment” temperatures are not kept correctly. Freeze sensitive vaccines are being frozen and thus the vaccines are loosing potency. In high altitude areas, where the temperature gets below zero vaccines are also being frozen, staff seems to think that the refrigerator can take care of negative ambient temperatures – this is NOT the case. Much of the equipment is above 15 years of age (that includes Solar Power – still running after 15 years!!), there is no recent (latest is 1994), countrywide, inventory of the cold chain equipment. The data that was collected in connection with introduction of CLM have gone missing, perhaps due to the frequent change of staff. The first thing to be done is to make a proper inventory, including age, type and condition of equipment, in other words to stake stock of what is available. Many areas are suffering from voltage fluctuation, voltage stabilizers are not in use. Voltage stabilizers must be introduced where needed. In high altitude areas 3 to 5000m, temperatures well below zero are frequent in cold season. There is no protection of freeze sensitive vaccines! It is recommended that “real” EPI-Cold Chain Equipment be introduced, equipment that has been tested and is listed in the WHO/UNICEF publication Product Information Sheets. Latest version attached as *.pdf file. Waste management, not included in the TOR, was also looked into, there is much work to be done in that area.

5

Mission objectives (as received)

• During the consultancy period the following outputs will be achieved: • Evaluation of the existing situation regarding the central cold store located at

the national warehouse of the Ministry of Health: equipment, cold rooms, alarm and monitoring system. Equipment maintenance and repair. Power supply and related factors. Emergency management and response. Cold chain management, including human resources capacity.

• Evaluation of cold chain in one department at the country side, where the “Programa de Cooperacion Peru-UNICEF” is being conducted, with assessment of vaccine storage conditions and refrigeration equipment at the department and district level

• Design and development of a first proposal for a countrywide assessment of the cold chain and its existing situation, including equipment requirements, costs and other resource implications such as identification of donor funding options

Debriefing at MINSA on 14.08.03: A power point presentation was made. Participants: Dr. Alvaro Vidal - Minister of Health Mr. Andrés Franco - UNICEF Lima Representative Dr. Mario Tavera - UNICEF Health Officer Dr. Paulo Froes - Regional EPI Adviser

Dra. Nora Reyes - Health People Programme Director

Dr. Yuri Alegre - Family Group Director

Dra. Maritza Tsuchida - Ages of Life Director

Ms. Carolina Cerna - EPI Staff Member

Dr. Jorge Medrano - EPI Staff Member

Ms. Lucia de Oliveira - EPI PAHO

Mr. Eduardo Zegarra - Cold Chain Technician Exit Meeting with Unicef, Information Officer and Journalist.

6

MINSA: WIC/WIF

The Cold Store consists of a WIC (ca. 50m³) and a WIF (ca. 50 m³) in addition a new Japanese combined WIC&F was installed a couple of years ago, (ca. 50m³), very good quality. The old WIC&F are of US origin approx. 20 years of age, they are very well maintained and look like new rooms. Well done! The old WIF&C are using CFC-gases and the WIF is currently

Picture 1

being upgraded to being CFC-free. Other than EPI supplies are being stored in the cold rooms e.g. HIV/AIDS test kits. More space is needed and it should also be considered that the equipment is getting old.

Picture 2 Picture 3

Vaccines are kept orderly and well organized. Temperature recording is very good.

7

Picture 4

Records are well kept, but would benefit immensely from being computerized.

Picture 5

A small digital thermometer with a 300 mm long and pointed sensor is being used to monitor the inside temperature of a cold box, without opening. Simply penetrate the Styrofoam.

Recommended Action Points for National Cold Store

Procurement and installation of two new combined WIC&F, ca. 50m³ (like the Japanese that was installed 2 years ago) to be installed. The store can easily be expanded to accommodate the new rooms.

Existing WIC be upgraded to CFC-free, this can be done locally.

Installation of a continuous computerized monitoring and automatic

dial-up alarm system (computerized data-logging, to be installed by a consultant, same consultant must set up a proper computerized inventory system both for vaccines and spare-parts).

All of above should be done with guidance of UNICEF and

procurements done through UNICEF Procurement Service to ensure good quality and fair prices.

8

Draft TOR for Temperature Monitoring and Inventory Consultant.

a. Review this report and meet with the writer. b. Travel to Peru, Lima meet with UNICEF and MINSA officials for

briefing. c. Review existing vaccine stock inventory and distributing system at

EPI Headquarters (MINSA). d. Set-up a proper vaccine stock inventory and distributing system at

EPI Headquarters. (In close collaboration with officers concerned) e. Set-up a proper temperature monitoring system for all refrigerated

vaccine storage facilities. f. Train officers in the use of new systems. g. Write report on findings, work carried out and recommendations.

Visits to Health Centers and vaccine stores in Lima, Cusco and Apurimac provinces.

Lima Province: Dirección de Salud Lima Sur Health Office - Southern Lima Almacén de Cadena de Frío

Cold Chain Warehouse Hospital Manuel Barreto Centro de Salud Ollantay

Health Centre Ollantay

This is an excellent idea (the cup in the center) to help avoid freezing in vaccine carriers.

Picture 6 Picture 7

9

Picture 8 Picture 9 Picture 10

8. Water bottles stored in the bottom of the domestic fridge, this is to stabilize the

temperature.

However, it would be better storing the bottles just below the evaporator in order to avoid freezing temperatures and the same time stabilize the

temperature.

9. Shows the temperature inside and ILR -2°C, the ILR had no ice-lining and staff was not aware that there was supposed to an ice-lining. The ILR was used for Hep. B.

Staff needs refresher training, ILRs without ice-ling can only be used for

storage of NON-freeze sensitive vaccines.

10. Rabies vaccine stored with EPI-vaccines, which is normal in Peru. Picture 11

Ice-packs are being taken directly from ice-pack freezer to cold-box. The store-keeper was asked to empty a fridge holding DPT. And she did as above, she was not aware of the risk of freezing the vaccines.

Staff needs refresher training! Picture 12

10

Cuzco Province: Almacén Cadena de Frío Red Norte

Cold Chain Warehouse/Northern Network

Dirección Regional de Salud Cusco

Cusco Regional Health Office

Almacén Regional de Cadena de Frío

Regional Cold Chain Warehouse

Almacén de Cadena de Frío Red Sur

Cold Chain Warehouse/Southern Network

Centro de Salud Paucartambo

Almacén Provincial de Cadena de Frío

Health Centre Paucartambo

Cold Chain Provincial Warehouse

Centro de Salud Pilcopata

Health Centre Pilcopata The cold chain is mapped and well organized. Picture 13

40 year old equipment, maintained and in use, fantastic!

Picture 14

15 year old solar powered equipment still running. Astounding maintenance work!

PCs are being used in Cusco Cold Chain. Picture 15 Picture 16

Ice-Packs are being stored at -40°C, that leaves great opportunities of freezing vaccines when packed!!

Staff needs refresher training!

Fuente.- FONCODES

MAPA DE POBREZA 2000 DEPARTAMENTO DEL CUSCO – 2000

(Estratos por Indice Relativo de Pobreza)

REGULAR 08

POBRE 44

MUY POBRE 44

EXTR. POBREZA 12

POBREZA DISTRITOS

11

Picture 17 One more ILR without ice-ling! Vaccines are being frozen!

Staff needs refresher training!

Picture 18

Safety boxes are not being used. Very dedicated and innovative staff is using used plastic bottles. Staff was advised only putting the needles in the bottle, without recapping. There is no proper waste management and incineration system in place. Picture 19

Innovative staff using electric heaters, hanging from the ceiling, when weighing and measuring babies! Picture 20

Baby, ready for weighing.

12

Picture 21

Vaccines arranged in ventilated cutlery tray !

Picture 22 Picture 23 Picture 24

Waste pit. The ground adjacent to the pit was full of used needles.

Staff was advised to clean up the ground – that had happened on our unexpected return visit a couple of days later.

Staff needs training in waste management!

13

Apurímac Province:

Picture 25 Picture 26 Picture 27 Picture 28 Picture 29

The above are temperature recording sheets, manually filled. The all show +2°C, the thermometer reads -1°C. The real temperature, during one night at approx. +15°C ambient and thermostat at maximum (coldest, as it was found) is shown in figure 1, below. Picture 30

Data logger with DPT vaccines!

Dirección Regional de Salud Apurímac

Regional Health Office Apurimac

Hospital de Chalhuanca (Mini)

Chalhuanca Hospital

Puesto de Salud de Quilcaccasa

Health Post - Quilcaccasa

Centro de Salud de Cotaruse

Health Centre - Cotaruse

Dirección Regional de Salud Apurímac

Regional Health Office Apurimac

14

Picture 31 Temperature in “Regional DPT-fridge”, the thermostat was set at maximum, this was the same for all fridges in the Regional Store!

Staff needs refresher training! Training alone will not do the trick.

Most of the equipment used in Peru is Domestic type of equipment; the temperature near the evaporator goes as low as -10°C.

The latest EPI equipment comes with electronic thermostats and has much better temperature profile. It is highly recommended that “real” EPI equipment be

introduced in the Peru cold chain!

Health Post at 4000m, having a solar powered refrigerator and solar power for communication and lights. All equipment has been working well for 3 years. Picture 31 Picture 32 Picture 33

15

Summary of recommendations: 1. Proper inventory, age, number and condition (Nepal model) by

external consultant. 2. Budget for re-equipping the cold chain 3. Computerized temperature Monitoring and Inventory System 4. Budget for Computerized temperature Monitoring and Inventory

System 5. Additional Staff and training of staff! 6. Training of existing staff, Cold Chain and Safety of Injection

(Waste Management), by external consultant. 7. Budget for introduction of waste management, by external

consultant. 8. Introduction of Incinerators or other type of safe destruction of

waste. 9. Supervision 10. Additional WIC/F 11. Phased introduction of WHO tested equipment, including voltage

stabilizers. 12. Use of UNICEF Procurement Services 13. Special equipment for High Altitude Areas 14. MINSA to identify Funding

annex

1

COLD CHAIN - PERU

Date City Provin

ce Institution People Met

04-Aug Lima Lima Ministerio de Salud

Dra. Nora Reyes - Health People Programme Director

Ministry of Health Dr. Yuri Alegre - Family Group Director Dra. Maritza Tsuchida - Ages of Life Director Ms. Carolina Cerna - EPI Staff Member Dr. Jorge Medrano - EPI Staff Member Ms. Lucia de Oliveira - EPI PAHO

Mr. Victor Gomez - Cold Chain Adviser 04-

Aug Lima Lima Almacén Central - Ministerio de Salud Mr. Luis Chipoco - Central Warehouse Director

Central Warehouse - Ministry of Health Mr. Eduardo Zegarra - Cold Chain Technician

04-Aug Lima Lima

Almacén Central - Ministerio de Salud Mr. Eduardo Zegarra - Cold Chain Technician

Central Warehouse - Ministry of Health

05-Aug Lima Lima Dirección de Salud Lima Sur Dr. José Valdivieso - Health Director

Health Office - Southern Lima Ms. María Alvarez - Responsible for EPI 06-

Aug Lima Lima Almacén de Cadena de Frío Ms. Rosa Mosquera - Warehouse staff

Cold Chain Warehouse 06-

Aug Lima Lima Hospital Manuel Barreto Ms. Zoila Cachay - EPI Nurse

Ms. Rosa Zumaeta - EPI Serums Nurse 06-

Aug Lima Lima Centro de Salud Ollantay Ms. Virginia López - EPI Nurse

Health Centre Ollantay Ms. María Augusta Mamani - EPI Technical Nurse 07-

Aug Cusco Cusco Almacén Cadena de Frío Red Norte Ms. Marina Ochoa - Director

Cold Chain Warehouse/Northern Network Mr.William Velasco - Staff

Ms. Isabel Fuentes - EPI/IC

Ms. Fabiana Rimache - Cold Chain Technician 07-

Aug Cusco Cusco Dirección Regional de Salud Cusco Dr. Wilber Holgado - Regional Director

Cusco Regional Health Office

07-Aug Cusco Cusco

Almacén Regional de Cadena de Frío

Mr. Antonio Páucar - Regional Cold Chain Technician

Regional Cold Chain Warehouse Ms. Isabel Fuentes - DISA Cusco 07-

Aug Cusco Cusco Almacén de Cadena de Frío Red Sur Mr. Edgardo Rivera - Manager in charge

Cold Chain Warehouse/Southern Network Ms. Luz Bernal - Responsible for EPI

08-Aug

Paucartambo Cusco Centro de Salud Paucartambo Ms. Rosa Alvarez -Responsible for EPI

Almacén Provincial de Cadena de Frío

Ms. Evangelina Carrasco - Responsible for EPI and Cold Chain

Health Centre Paucartambo

Cold Chain Provincial Warehouse

09-Aug Pilcopata Cusco Centro de Salud Pilcopata Ms. Kelly Portugal - Responsible for Cold Chain and

annex

2

Health Centre Pilcopata Health Personnel 11-

Aug Abancay Apurimac

Dirección Regional de Salud Apurímac Dr. Eden Casaverde - Regional Health Director

Regional Health Office Apurimac Mr. Segundino Serrano - Regional Cold Chain Technician

Ms. Miriam Monzón - Responsible for Cold Chain and EPI

12-Aug

Chalhuanca

Apurimac Hospital de Chalhuanca (Mini)

Ms. Rosaura Mendoza - Nurse responsible for Cold Chain and EPI

Chalhuanca Hospital Dr. Christian Torres - In charge of the hospital 12-

Aug Quilcaccasa

Apurimac Puesto de Salud de Quilcaccasa Ms. Emilia Sarmiento - Nurse

Health Post - Quilcaccasa 12-

Aug Cotaruse Apurimac Centro de Salud de Cotaruse Mr. Richard Quispe - Nurse

Health Centre - Cotaruse

13-Aug Abancay

Apurimac

Dirección Regional de Salud Apurímac Dr. Wilber Holgado - Regional Director (debriefing)

Regional Health Office Apurimac 14-

Aug Lima Lima UNICEF Office Dr. Mario Tavera - UNICEF Health Officer

Dr. Paulo Froes - Regional EPI Adviser

14-Aug Lima Lima UNICEF Office

Mr. Andrés Franco - UNICEF Lima Representative (debriefing)

14-Aug Lima Lima Ministerio de Salud Dr. Alvaro Vidal - Minister of Health (debriefing)

Ministry of Health

14-Aug Lima Lima Miraflores Park Plaza Hotel

Presentation of the Publication "The Health Promotor"

15-Aug Lima Lima UNICEF Office Mr. César Fonseca - Information Officer

Ms. Vera Lauer - Documentation Centre - UNICEF

Journalist (Press release