Journal of Public Health and Primary Care

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 2  |  Issue : 3  |  Page : 64--69

How immunization clinic and cold chain point are organized and functioning? – Status of a tertiary care hospital, West Bengal


Arup Chakraborty, Debasis Das 
 Department of Community Medicine, Medical College, Kolkata, West Bengal, India

Correspondence Address:
Dr. Arup Chakraborty
240, Golpukur Road, P. O. Baruipur, Kolkata - 700 144, West Bengal
India

Abstract

Background: Universal immunization program is one of the large public health programs in our country which plays very crucial role to improve child's health and reduce infant and under-five mortality. Aim: The study was planned to determine the organization of the immunization clinic and cold chain point and to assess the managerial problems and finding out probable solutions. Materials and Methods: It was an observational study done in 2016 in the immunization clinic of Medical College, Kolkata. A predesigned and pretested data collection form, relevant registers and records, a checklist of Government of India was used for collecting data. Interviewing different stakeholders, examination or records, and observation of functions was done. Results: The study revealed few major issues like lack of knowledge and motivation among the staffs. Limited supervision by the higher authority and uneven supply chain especially for Vitamin A was also highlighted. Conclusion: Priority analysis found that the most priority issue of the immunization clinic was the lack of knowledge of the Public Health Nurses and Junior Doctors. Hence, most suitable intervention was to arrange a training session for the Doctors and the nurses. The detailed action plan and budget regarding the training activity were also calculated. Clinical Significance: Success of Universal Immunization Programme depends on cold chain planning, maintaining and evaluation of temperature-sensitive vaccination program. Hence, the present study of cold chain organization and functioning is immensely important repeatedly over time.



How to cite this article:
Chakraborty A, Das D. How immunization clinic and cold chain point are organized and functioning? – Status of a tertiary care hospital, West Bengal.J Public Health Prim Care 2021;2:64-69


How to cite this URL:
Chakraborty A, Das D. How immunization clinic and cold chain point are organized and functioning? – Status of a tertiary care hospital, West Bengal. J Public Health Prim Care [serial online] 2021 [cited 2022 May 27 ];2:64-69
Available from: http://www.jphpc.com/text.asp?2021/2/3/64/333898


Full Text



 Introduction



Organizational effectiveness is defined as the ability of an organization to achieve its desired level of performance. The performance is determined by the contextual environment in which health organization functions and how well those interact with its environment. The environment of the health care organization is to be perceived to include the physical, social, and organizational contexts. Any health organization system consists of Human Resource, Support System, Planning, Monitoring, and Evaluation System, Community Participation and Intersectoral co-ordination function.[1]

Universal immunization program (UIP) is one of the biggest program operating even in the remotest areas of this country to improve child's health and reduce infant and under-five mortality. This program is implemented through fixed immunization clinics of health care institutions at different levels, outreach session, and National Immunization Days.

The current study was planned to assess the structure and function of Immunization clinic and cold chain point in a tertiary care setting of West Bengal which are crucial for the success of UIP.

 Materials and Methods



Type of study

It was an observational study, cross-sectional in design.

Period of study

The study was conducted over 6 months between July and December 2016.

Place of study

Immunization Clinic of Medical College, Kolkata.

Objectives

The study was planned to determine the organization of the immunization clinic and cold chain point in terms of structure, and function, and to assess the managerial problems faced by Public Health Nurses (PHNs), internees, and post-graduate students in the smooth running of the immunization clinic.

Materials

A predesigned and pretested data collection form for collecting primary data was used. Secondary data like monthly reports, service registers, attendance records of the staffs, records of indent, and supply of vaccines were collected and analyzed to find out the performance of the clinic. A checklist of Government of India was used for evaluating cold chain points and equipment.

Methods

For collecting primary data, the interview was conducted with the help of a predesigned semi-structured data collection form with the caregiver of the beneficiaries attending the immunization clinic. To assess the managerial problems key informant interview[2] was conducted with PHNs, cold chain handler (CCH), interns, postgraduate students. Direct observation was done with the help of the checklist as mentioned above to assess the cold chain point and equipment. Secondary data was collected by examining relevant records.

Data analysis

It is a descriptive study data of which is being described as per the cold chain process sequence. Data of mother's interview were entered and analyzed in Microsoft Excel Workbook, version 2007. Relevant proportions were calculated and tabulation was done.

 Results



Physical infrastructure of immunization clinic

The immunization clinic was under the control of the Department of Community Medicine, of Medical College, Kolkata. Three rooms were dedicated for routine immunization (RI) activities; one room at the ground floor (120 square foot floor area), runs the immunization clinic. The room had 3 tables and 10 chairs. Two tables were being used by PHNs for preparation and giving vaccine and one table was used by the junior doctors for weighing the children, documentation, and offering health education. There was an almirah for keeping different registers and logistics. Different health education materials were being displayed on a wall-mounted board. A washbasin was present with water connection for hand washing. Only blue and black colored bucket for biomedical waste (BMW) segregation and disposal were in use. Being situated in the ground floor, the room temperature was comfortable, well ventilated, not exposed to direct sunlight, and adequately illuminated with artificial light. There was no attached toilet present with the immunization clinic. Beneficiaries had to use pay and use toilet located 50 m away from the clinic. Other two rooms were part of the Department of Community Medicine at the fourth floor. One was dedicated for the cold chain and the other for the dry stock storage. Cold chain room was equipped with two functional ice-lined refrigerators (ILRs) and one functional deep freezer (DF). Functional cold box and vaccine carriers were also available.

Resources available for the immunization program

Human resource

Employees have been traditionally viewed as assets to the organization. Human resource management is a function in organizations designed to maximize employee performance of an employer's strategic objectives.[3] The Staffing pattern of the immunization clinic was as follows.

Overall in charge was Professor and Head, Department of Community Medicine. Faculty in charge of immunization clinic was an Assistant Professor. Five Public nurses were posted; among them one PHN was being nurse's in-charge. Post Graduate trainee (one at a time) posted by rotation for 3 months and group of internees (batch of 6–7 at a time) posted by rotation for 2 months. Among nontechnical staff, two group D staffs used to help in the activity of the clinic along their regular activity of the Department. No dedicated sweeping staffs were present in that clinic; this function was shared by the common sweeping staffs of the building.

Material resources

Vaccines and logistics were regularly supplied from the Central Vaccine Store, Kolkata. Monthly indents were being done by the PHN in-charge with the consultation of the faculty in charge of the immunization clinic. There was a prescribed indent form available for that purpose. The Cold chain equipment (CCE) was supplied by the office of the District Family Welfare Officer, Kolkata. Valid annual maintenance contract from M/S J. M Traders of Kolkata which is supposed to send a cold chain technician (CCT) every 3 months interval for routine maintenance of the CCE.

Financial resources

As it was a Government organization, the necessary money already allotted in the health budget at the beginning of the financial year. The total budget allocation for the vaccines, logistics, infrastructural expenditure as well as the salary of the employees was distributed under capital and routine budget heads.

Performance of the clinic

249 children aged 9–11 months and 199 children aged between 12 and 23 months have been fully immunized[4] in that clinic during the study period. A total of 1199 children's growth monitoring was done using WHO growth charts (new) during the study period. A total of 193 international travelers were inoculated with oral polio vaccine during the study period and the total no. of postexposure rabies prophylaxis given through (Modified Thai) intradermal regimen during the study period was 218.{Figure 1}

Indent and supply of vaccines at the clinic

Regular indenting practice was observed during the study period and almost all the vaccines and dry stock were supplied as per the requirement except Vitamin A oil due to nonavailability at the central store.

Visit of maintenance worker

One visit of CCE by maintenance worker was paid in the period of study though as per contract it was supposed to be one in each quarter, i.e. 2 in 6 months.

Adverse effect following immunization reported by the clinic

Adverse effect following immunization (AEFI) is any untoward medical occurrence that follows immunization and which does not necessarily have a causal relationship with the usage of the vaccine.[5] The report of AEFI suggests poor quality of vaccination. It needs to be reported each month according to the guideline. Even nil report has to be submitted regularly. It was found that regular report in each month was submitted as per the guideline and there was no major AEFI was reported during that period.

Attendance of staffs

For PHN, the average person-day of work during that period was calculated as 128.8 days and average absence was 33.3 days, i.e., average of 25.8% person-days were lost due to absenteeism of the primary category of staffs. The important causes of absenteeism were child care purpose, sickness, family purpose and availing earned leave.

Status of cold chain equipment

It was carried out using monitoring format of Cold Chain point and equipment by Govt. of India.[6]

There were two ILRs and one Deep Freeze (DF) in the clinic. One ILR and one DF found non-functional. All the CCE available was new and aged <10 years. All three functional equipment were CFC free. No. of functional cold box was one; smaller in capacity (5 L). The cold box was clean and dry from inside. There was no nonfunctional cold box available for repair. Two functional stabilizers which were attached to the CCE were found in the place. Both were attached with the two ILRs. The deep freeze was devoid of stabilizer connection. There was no nonfunctional stabilizer were available for repair. All the CCE were placed inside a room and were away from direct sunlight, moisture and rain. Each of the CCE was placed on wooden stands and each having a gap of minimum 10 cm from the adjacent walls as per recommendation. During physical examination there was not a single CCE found having frost >5 mm on the inside wall. Being placed in the Medical College campus, the CCE room did not face any problem of power failure and that's why there was no functional power back up system in place.

The ice packs were placed correctly inside the DF for freezing at the time of physical verification and those were also correctly filled with water up to the mark and capped. There was no dedicated table available for conditioning of ice packs and it was being done on the top of a condemn ILR with the help of a piece of clean cloth available for wiping of ice packs after conditioning. There was a separate place available for keeping dry stock like syringes, registers, and other logistics.

Vaccine and diluents storage temperature

There was separate functional thermometer available for each functional CCE and those were placed correctly inside the CCE on the day of visit. Separate temperature logbook was available for each functional CCE and temperature was found recorded twice daily and documented in the logbook. However, there was no recording of temperature on Sundays and Holidays as no CCH was staying nearby to come and record the temperature on those days. Records of defrosting and cleaning were present in the temperature logbooks during the study period. During the physical examination, the cabinet temperature of all functional ILRs and DF was found within the recommended range that was +2°C to +8°C for ILR and −15°C to −25°C for DF.

Vaccine management and handling

There was only UIP vaccines present in the ILR and the diluents of BCG and Measles kept inside ILR all the time. Vaccines were stored in the ILR within designated basket. T-series/Hepatitis B vaccines were placed in the top of the ILR as per recommendation. All the vaccines vials were found with proper readable labels and within expiry dates. At the time of physical verification, all the vaccine vials were found with usable VVM (stage I and II) and no vaccines were found in frozen condition. As opened vial policy was in place, so few opened vials of Hepatitis B, TT, and DPT were found inside the ILR, placed in a separate zipper bag having date and time recorded on the vial. Though CCH had adequate knowledge regarding the freeze-sensitive vaccines but they failed to answer about the “Shake Test.”

Management Information System, Information Education and Communication and supporting management system

The National Cold Chain Management Information system for this CCP was not complete and vaccine and logistic MIS was mainly paper based and it was also not updated till last transaction during study period. The frequency of visit of the CCT was not regular. During the study period CCT had visited the facility only once. Though the stock registers were maintained as per norm and all parameters for vaccines, logistics and diluents were recorded but the returned and partially returned vials were not entered in the stock register. No documentation was also available on expired and wasted vaccine. There was no record of physical counting of vaccine stock by CCH during the study period, though the physical counting of freeze dried vaccines was matching with the stock on the day of verification. AEFI was reported in every month (including zero) in HMIS report.

There was no emergency plan visible in the cold chain room, though charts on vaccine and ice pack arrangements were available. Hoarding, wall paintings, banners related to RI were present in the clinic as well as in the main campus.

Key informant interview of the major stake holders

Key informant interview was conducted to the major stake holders like, junior doctors, post graduate trainees and PHNs. It was found that the knowledge regarding different aspects of vaccines and cold chains were adequate among them and they were also abiding with different rules and regulations of the clinic. Few issues that had come up at the time of the interview were provision of a dedicated sweeping staff and store keeper for the clinic, provision for an attached toilet for the clinic.

Interview of the mothers of under-five children

The most common reason for coming to the clinic was either staying nearby or had delivery in this institution. At on average two visits were paid by the mothers in the clinic and the average time spend in the clinic was <0.5 h. Not even a single mother was asked to wait for at least 30 min after vaccination which is recommended guideline. 83.33% of mothers were not informed regarding the vaccines given and the rests were correctly informed as per records. 50% of the mother was informed regarding the next vaccination date but hardly little documentation was available in the cards. 66.67% of mothers were told about the side effects of the vaccine given on that day and what to do if it would happen.

Only 16.67% of mothers had received other types of health advices from the clinic and most common were dietary advices of the mother. Not even a single mother had received health education on Family Planning. 83.33% children's weight were measured and recorded in the cards but surprisingly it was found that none of the mothers was informed about their children's weight and it was also not plotted against the growth chart attached with the Mother and Child Protection Card. Only 16.67% of mothers received dietary advice for their children. 83.33% of mothers were satisfied with the general cleanliness of the clinic room and the surrounding area while the rest of them wanted improvement of the cleanliness of the clinic. Almost all the mothers were satisfied with the behavior of the nursing staffs of the clinic and also want to refer their relatives in that clinic in future.

 Discussion



The present study was conducted to determine the organization of immunization clinic and cold chain point in terms of structure, and function, and to assess the managerial problems faced by PHNs, internees, postgraduate students and in charge for the smooth running of the immunization clinic. Once data gathered regarding structure, function of the center four core managerial problems were identified as (a) deficient knowledge of PHN and Doctors in some aspect of immunization and cold chain, (b) lack of motivation depicted by frequent absenteeism, (c) lack of supervision in some areas and (d) inadequacy of certain supply [Diagram 1].

Considering resource constraint in all settings a prioritization exercise was conducted to make a priority list by giving 10 point score in five domains such as feasibility, requirement of extra manpower, material required, requirement of additional money, time required, and type of implementing authority. The total score of each domain was calculated and a priority list was prepared for intervention. From this process 'Training of PHN and Junior Doctors' tops the list; improvement of supervision and monitoring, building toilet attached to the clinic supply of drugs and other logistics and improvement of motivation of staffs follows [Table 1].{Table 1}

The top priority problem was inadequate knowledge of the PHNs and Doctors regarding various issues of immunization. So, training and capacity building on related issues would be the most suitable mode of intervention. The specific training agenda would be different UIP vaccines including post-exposure intradermal rabies prophylaxis, shake test, mother and child tracking system, BMW management in immunization clinic, and cold chain. Hands-on training would also improve skill on safe injection practices, temperature recording of CCEs, proper documentation, placement of different vaccines and ice packs inside the ILRs and DFs respectively, art of interpersonal communication including delivery of four key messages, record-keeping including maintenance of stocks, weight measurement and plotting in the WHO growth chart. A Log frame was analysis was done for training [Table 2].{Table 2}

 Conclusion



By doing the situational analysis it was found that the most priority issue of the immunization clinic of Medical College, Kolkata was lack of knowledge of the PHN and Junior Doctors. Hence the most suitable intervention was to arrange a training session for the Doctors and the nurses. The action plan in the form of log frame analysis had been done and different activities against the time frame (Gantt chart) were planned. Necessary budget regarding the training activity was also calculated.

Clinical significance

UIP is devoted at protecting all the children of our country from major childhood killer diseases. The success of UIP depends on the selection of antigens in the National Immunizations Schedule on one hand and planning, implementing and evaluating of the program on the other hand. Cold chain planning, maintaining, and evaluation has heavy toll on the success of this temperature-sensitive vaccination program. Hence, the current type of evaluation studies of cold chain organization and functioning is immensely important repeatedly over time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Wikipedia. Organizational Effectiveness. Available from: https://en.wikipedia.org/wiki/Organizational_effectiveness. [Last accessed on 2019 Feb 05].
2Ucla Center for Health Policy Research. Key Informant Interview. Available from: http://healthpolicy.ucla.edu/programs/healthdata/trainings/Documents/tw_cba23.pdf. [Last acessed on 2019 Feb 05].
3Human Resource: Available from: http://www.whatishumanresource.com/human-resource-management. [Last accessed on 2019 Feb 05].
4Immunization – National Institute of Health & Family Welfare. Available from: http://www.nihfw.org/pdf/nchrc-publications/immunizationeng.pdf. [Last accessed on 2019 Feb 05].
5The Immunization Advisory Centre. Adverse Effect Following Immunization: Available from: http://www.immune.org.nz/adverse-events-following-immunisation-aefi. [Last accessed on 2019 Feb 05].
6Available from: http://www.nccvmtc.org/PDF2/2_070.pdf. [Last accessed on 2019 Feb 05].