Introduction
Careful attention to vaccine storage is essential to ensure optimal vaccine effectiveness. The system used for keeping vaccines in good condition is called Cold Chain. It consists of a series of storage and transport links, designed to keep the vaccine at the correct temperature until it reaches the user. This study was conducted in order to describe the current status of the vaccine cold chain maintenance and to identify the deficiencies in the different elements of the vaccines cold chain maintenance at the health care facilities in Riyadh and Eastern Region of Saudi Arabia.
Methodology
A cross-sectional study was conducted in a sample of 60 governmental and private health centers in both Riyadh and Eastern region. A stratified random sampling technique was used. A questionnaire was used for data collection that included identification data, observational data to evaluate vaccination room, EPI-vaccines refrigerator, temperature monitoring devices, vaccine status inside refrigerator and records. For assessment of each health facility, a cumulative score was developed based on 84 questions. For statistical analysis p-value - chi-square, mean and t-test were used.
Results
In Riyadh city 37 health facilities were included. All have one person at least assigned for EPI cold chain maintenance and all of them were females, of whom 48.6% were Saudi and 51.4% non-Saudi. A separate vaccination room was provided at 86.5% of health facilities in Riyadh. All the visited health facilities had well-functioning refrigerators with doors that closed well and were stable while opening. Only 32.4% were more than 20 cm from nearest wall. Regarding the ice thickness in freezers, 59.5% of freezers had ice less than 5mm thickness. 56.7% of health facilities the vaccine refrigerators were used only for vaccines. None of the visited health facilities had refrigerator for personal use. It was found that 83.8% had a functioning thermometer. Among available 87.1% were placed in the correct location and all of them showed correct reading. Only one health facility 2.7% had functioning freeze watch that had a correct location and reading. 86.5% of VVM on Polio-vaccine revealed good temperature maintenance, 75.7% had temperature chart and in 56.8% the number of times the temperature recorded last 7 days was 10 times or more. Regarding vaccines availability, OPV (100.0%), MMR (97.3%), Rubella (27.0%) Hepatitis B (97.3%), DPT (89.2%), DT (45.9%), Hib (91.9%), Meningitis (59.5%) MMR Dil. (97.3%) and Rubella Dil (35.1%). More than 70.0% were labeled. Only one OPV vial had sediments. None of the vaccines expired and between 40-70% of the vaccines had adequate space. Vaccines records and registration revealed that 37.8% had manual for cold chain maintenance, 75.7% had vaccine stock register, 78.4% had vaccine expiry record, 64.9% had updated records and 27.0% only had alternative electric supply. Eastern Region:23 health facilities were included. All had one person at least assigned for EPI cold chain maintenance and all of them were females, of whom 60.9% were Saudi and 39.1% non-Saudi. A separate vaccination room was provided at 82.6% of health facilities in Eastern Province. All the visited health facilities had well-functioning refrigerators with doors that closed well and were stable while opening. 73.9% of the refrigerators were more than 20 cm from nearest wall. Regarding ice thickness in freezers, 95.7% of freezers had ice in freezer less than 5 mm thickness, and 65.2% of health facilities the vaccine refrigerators were used only for vaccines. None of the visited health facilities had refrigerator for personal use. It was found that 95.7% had a functioning thermometer. Among available 81.8% were placed in correct location and all of them showed correct reading. Only one health facility 4.4% had functioning freeze watch that had correct location and reading. 95.7% of VVM on Polio-vaccines revealed good temperature maintenance, 95.7% had temperature chart and in 95.7% the number of times the temperature recorded last 7 days was 10 times or more. Regarding vaccines availability, OPV (100.0%), MMR (100.0%), Rubella (43.5%) Hep B (95.6%), DPT (69.6%), DT (43.5%), Hib (100.0%), Meningitis (65.2%), MMR Dil. (100.0%) and Rubella Dil (43.5%). More than 90.0% were labeled. Only one Rubella Dil. vial had sediments. None of the vaccines expired and more than 70.0% had adequate space. Vaccines records and registration revealed that 73.9% had manual for cold chain maintenance, 87.0% had vaccine stock register, 78.3% had vaccine expiry record, 78.3% had updated records and 30.4% had alternative electric supply. Scoring:On the basis of room and refrigerator score, maximum score was 11, Riyadh Region Mean + S.D. = 8.8 (80.0%) + 1.38 while its 9.5 (86.4%) + 1.34 in Eastern Province. T-test = 2.11 and p-value was significant (p-value = 0.04). Temperature devices and records score was out of 10. Riyadh region score was Mean + S.D. = 5.2 (53.0%) + 2.27 while in Eastern Province = 6.7 (67.0%) + 1.18. T-test = 2.73 and p-value was significant (p-value < 0.01). Vaccine status and management score was out of 57. Riyadh Region score 34.5 (60.5%) + 10.46 while in Eastern Province = 39.4 (69.1%) + 10.73. T-test = 1.75 and p-value was insignificant (p-value = 0.09). Vaccine stock management score was out of 6. Riyadh Region score 3.8 (63.3%) + 1.52 while in Eastern Province = 4.5 (75.0%) + 1.41, t-test = 1.63 and p-value was insignificant (p-value=0.11)
Conclusion
This study revealed that Eastern Province was more precise in implementing WHO recommendations in elements affecting the performance of cold chain. Also, it pointed to the need for providing each health facility with a refrigerator for personal use to restrict EPI refrigerator usage for vaccines storage only. Training of staff, especially from Riyadh regarding maintenance of cold chain for EPI vaccines need.